Client Information
Full Name
Date of Birth
Phone Number
Email
Insurance Information
Insurance Company
Member ID
Group Number
Primary Insured Name
Relationship to Client
Primary Insured Date of Birth
Insurance Phone # (Provider)
Nutrition Counseling Coverage
Is Nutrition Counseling Covered?
Yes
No
Requires Medical Diagnosis
Number of Visits Allowed
Authorization Required?
Yes
No
Copay/Coinsurance
Deductible
Notes
Verification Details
Date Verified
Spoke With
Additional Notes