Does My Insurance Cover Forte Strong

Patient Name*
First Last
Patient Date of Birth*
MM slash DD slash YYYY
Policy Holder Name*
First Last
Policy Holder Date of Birth*
MM slash DD slash YYYY
Insurance Provider*

United Healthcare requires that the patient/policy holder to call in and give permission for Forte Strong to obtain the out of network benefits for behavioral health services. In order to process this VOB request you will need to call in and give this permission for Forte Strong to verify your benefits.
Insurance Policy #*
Insurance Phone*
Have you called United Healthcare for VOB permission?*
- Yes
- No
Who Should We Send Results to?
Name of Respondent*
First Last
Email Address*
Phone Number*
FRONT of Insurance Card*
Max. file size: 50 MB.
Please upload an image of the FRONT of your Insurance Card
BACK of Insurance Card*
Max. file size: 50 MB.
Please upload an image of the FRONT of your Insurance Card