TAO Wellness Center - Insurance & Payment

Payment
- Cash
- Check
- Debit card
- Visa and Master card

Insurance

Name:
Date:
Address:
City:
State:
Zip Code:
Date of birth:
	M: F:
Home Phone:
Cell Phone:
Work Phone:
E-mail:
Emergency Contact:
Phone:
Insurance Provider:
Policy#:
Claim#:
Type of Insurance:
Insurance phone number:
Employer:
Occupation:
Address:
City/State:
Zip Code:
How did you find us? (Select one)
Other:
Chief complaint:
What kind of treatment are you interest?:

By submitting this form, I understand that my personal information will be used only for insurance purposes and verification. It will only be accessible to Tao Wellness Center staff and the insurance company, no third parties.

I have the right to request a copy of this information provided to Tao Wellness Center and the insurance company.