Insurance check request

This form asks our billing partner to check your insurance benefits. It does not confirm coverage, admission, or an appointment. Our team will contact you after the check.

This form is not monitored for emergencies. If you are in crisis, call or text 988. For a medical emergency, call 911.

1. Patient

Enter the name exactly as it appears on the insurance card or legal ID.

Legal first name (and middle name, if any) Legal last name (surname) The patient has only one legal name (no surname). Selecting this holds your request for staff review; it is not sent to billing until staff confirm your name. Patient's date of birth Mobile phone (phone or email required) Email (phone or email required)

2. Insurance

Insurance company / plan name as printed on the card Member ID exactly as on the card, including any letters or leading zeros Group number (optional) Other insurance (optional) The patient is the policyholder. Uncheck if a parent, spouse or someone else holds the policy. This is TRICARE / TriWest / military insurance.

3. Visit

Requested service Do you have a referral?

Choose “Yes — I will upload it” to attach your referral below.

4. Insurance card photos

Add clear photos of the front and back of the patient's actual insurance card (the card from the plan named above). Lay it flat in good light and fill the frame so every number can be read. Photos of other cards (business, appointment or pharmacy discount cards) cannot be used. Our system checks that each file is a complete photo, but it does not read the card: our billing partner relies on what you upload.

Front of card

Take photo Choose photo or file

No photo yet.

Back of card

Take photo Choose photo or file

No photo yet.

5. Confirm

The information is accurate, and I am the patient or legally authorized to act for the patient. The photos show the front and back of the patient's current insurance card, and the numbers are readable. I authorize NovoTelehealth to share this information and the card images with its billing partner to check insurance benefits.

Request received

Your confirmation code:

Take a screenshot or write down this code.