Insurance Verification Form

ClearVision accepts all major health insurance plans. Verify your insurance today by filling out the verification form below or give us a call at 570.450.0686.

* Indicates required field

Your Name *

First

Last

Who is seeking treatment? *

Yourself A loved one

Callback Number *

Email *

Insurance information

Policy Holder's Name *

Policy Holder's Date of Birth (mm/dd/yyyy) *

Patient's Date of Birth (mm/dd/yyyy) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Insurance Company's Name *

Insurance Company's Phone Number *

Member ID # *

Group # *

Policy Holder's Relationship to Patient *

Submit

​Insurance information

Insurance information