THANK YOU for your interest in our holistic health services!
Our billing team has a turn around time of ~48 hours Monday through Friday. They are closed weekends and holidays. As soon as the verification is complete, we will contact you to let you know your coverage and set up an appointment.
Please copy and paste the following information and send by email ASAP to mibasoholistichealth@gmail.com
MiBaSo®
www.MiBaSo.org Phone 786.537.0771
INSURANCE VERIFICATION FORM
Patient Name:
__________________________________________________________
Patient Address:
________________________________________________________
City, State, Zip:
_________________________________________________________
Patient Phone number:
___________________________________________________
Date of Birth:
____________________________Male/Female:
__________________
Patient Subscriber ID #:
__________________________________________________
Group#:
_______________________________________________________________
Relationship to insured:
__________________________________________________
Single/Married/Other: ____________________________________________________
Insurance Company name:
________________________________________________
Insurance company phone #:
_______________________________________________
Claim # if accident: ______________________________________________________
Date of accident/injury:
___________________________________________________
Other info.:
____________________________________________________________