Submit for Verification of Benefits

For patients or providers
Benefit Verification

CMB Client Services

To receive your benefit breakdown, please complete this form in its entirety. *Required Fields

Practice Name

Date

Patient Name

Date of Birth

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Primary Insurance Name

Primary Policy Number

Requested Services*

Secondary Insurance Policy*

Do you have a seconday Insurane you would like to bill?

Yes

Additional Notes and Questions

Insurance Card Front*

Upload File

Insurance Card Back*

Upload File

File Upload*

Upload File

I have read and understand the disclaimer.View Disclaimer

Thanks for submitting!