We’re in network with many leading insurance providers. Fill out the form below to find out if your insurance company will cover your treatment costs at SpringBoard.

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Your Name

Your Email

Your Relation To Patient

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(The primary person on the insurance policy)

Primary Insured Name (*)

Primary Insured Date of Birth (*)

Primary Insured Email

Primary Insured Phone (*)

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(The person that needs treatment)

Patient First Name (*)

Patient Last Name (*)

Patient Phone (*)

Insurance Provider (*)

Patient Date of Birth (*)

Insurance Phone (*)

Insurance ID Number (*)

Group ID Number (*)

Type of Plan (*)

Additional information