Verification of Benefits

Please complete the Verification of Benefits Request Form found on this webpage. We will speak to your insurance provider to verify which benefits are covered with your health plan.

Patient Information

Please provide the information for the primary policy holder of the insurance plan. In some instances, the policy holder is not the patient, and is typically the person who is financially responsible for the policy's monthly premium.

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Visit Information

Please provide information on which healthcare provider you would like to visit, and which healthcare service you would like to receive.

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Submitting this form does not guarantee insurance coverage of benefits, and is provided as a free service to you on behalf of Complete Wellness. You can request a copy of your verification of benefits form by contacting the medical records department of the provider's office. Upon verification, a completed Verification of Benefits form will be submitted to your healthcare provider to help determine the patients financial responsibility.