Verify Insurance Coverage

Understanding that using insurance is ideal, we will work quickly to identify how to best utilize your plan. Please provide the following information, and we will get back to you within 24 hours.

"*" indicates required fields

Patient Name*

Patient DOB*

Contact Name*

Phone*

Email*

Primary Insurance Holder Name*

DOB*

Insurance Provider*

Phone*

Member ID #*

How I heard about Synergy*

Name

This field is for validation purposes and should be left unchanged.