Insurance Intake Form
Please take a moment to fill out our online insurance form before your visit. All information is kept completely confidential. We will be in touch with the results of your insurance inquiry by email. 
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First and Last Name *
Email *
Mobile Phone *
Insurance Carrier  *
If other insurance carrier please specify below.
Insured Person's Name *
Insured Person's Date of Birth *
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/
DD
/
YYYY
Relationship to Insured *
Insured Person's Sex *
Insured Person's Address *
Member ID # *
Group/Policy # *
Plan Type *
Effective Date *
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/
DD
/
YYYY
Provider Customer Service Phone Number (usually found on the back of the insurance card)  *
I certify that the above medical information is correct to my knowledge. *
Privacy and the sharing of information: I authorize the Double Happiness Health clinic and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorize the clinic and its associated health professionals to communicate with my  insurance carrier, family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission. *
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