Check Your Health Insurance Benefits

Complete this form to receive your insurance benefits before receiving services

- Step 1 of 6

1. Select Your Health Insurance

Select Health Insurance Carrier *

If you were involved in an auto accident (and have an open and billable case), you can select "Auto Insurance".

If you were involved in an work accident and seeking rehab as part of a workman's compensation policy, you can select "Workman's Comp".

Insurance not listed?

If your insurance plan is not listed, select "Other" from the list instead. We accept all health insurance, but because thousands of policies exists and are continuously updated, yours may not appear on this list.

Looks like we don't have your health insurance listed *

Select Your Auto Insurance Company *

Select your auto insurance name from the drop down list. If not listed, select "Other".

Looks like we don't have your auto insurance listed *

Workman's Compensation Insurance Company *

Do you have a Secondary Health Insurance? *

Select Secondary Health Insurance Carrier *

Using Auto Insurance?

If you were involved in an auto accident (and have an open and billable case), you can select "Auto Insurance".

Using Workmans Compensation?

If you were involved in an work accident and seeking rehab as part of a workman's compensation policy, you can select "Workman's Comp".

Insurance not listed?

Looks like we don't have your secondary health insurance listed *

Select Your Auto Insurance Company *

Select your auto insurance name from the drop down list. If not listed, select "Other".

Looks like we don't have your auto insurance listed *

2. Select How You'll Provide Insurance Information

You can easily provide insurance information in one of two ways:

Complete on online form or upload pictures of your insurance card.

How would you prefer to submit your insurance information?

Select your preferred method of submission: *

Online Form
Upload Images

2. Gather Information Needed

You'll need the following auto insurance information for the next step:

- Claim Number - Date of Accident - Claim Adjuster Name - Claim Adjuster Phone

Additionally, if you have a supplemental health insurance plan, to be used in conjunction with your auto insurance, you'll need your insurance card

2. Gather Information Needed

You'll need the following workman's compensation information for the next step:

- Claim Number - Date of Injury - Claim Adjuster Name - Claim Adjuster Phone

3. Submit Insurance Information

Enter Health Insurance Card Information

Using your health insurance card, complete the fields below.

Your Full Legal Name *

First

Last

Your DOB *

Primary Health Insurance Information

Using your primary/main health insurance card, complete the fields below.

Your Full Legal Name *

First

Last

Your DOB *

Is the insurance policy under your name? *

Select "Yes" if: You opened the insurance policy. This may also be true if you receive this insurance through your employer.
Select "No" if: Your spouse or family member opened the insurance policy. This may also be true if your spouse/family member receives this health insurance through their employer.

Is the insurance policy holders name listed on the card? *

Since you did not open the insurance policy yourself, your spouse/family member who did open the insurance policy should be listed on the card. In rare cases, their name may not be present.
Select "Yes" if: Your spouse/family member who did open the insurance policy, is listed on the card.
Select "No" if: Your spouse/family member who did open the insurance policy, is not listed on the card.

Subscribers Full Name *

First

Last

The 'subscriber' is the main person named under the insurance policy. This is you if the policy is under your name (enter your name). This is NOT you if you are listed under a spouse or parents insurance policy (enter that person's name). This may NOT be you if you are under a spouse or parents insurance policy.

Subscribers Full Name *

First

Last

Subscriber's DOB *

Member/Enrollee ID *

Usually listed on front of your insurance card and may consist of both letters and numbers.

Group Number

Usually listed on front of your insurance card. Notice: If you have regular Medicare (not Medicare Advantage), you will NOT have a group number and can leave this field blank. If you do have a Medicare Advantage plan OR any other insurance, you WILL have a group number.

Insurance Providers/Customer Service Phone (Usually listed on back of your insurance card) *

Usually the provider or customer service number is listed on the back of your insurance card.

3. Submit Insurance Information

Enter Workman's Compensation Insurance Information

Your Full Legal Name *

First

Last

Your DOB *

3. Submit Insurance Information

Enter Auto Insurance Information

Your Full Legal Name *

First

Last

Your DOB *

3. Submit Insurance Information

Using your Auto Insurance information, answer the questions below.

Your Full Legal Name *

First

Last

Your DOB *

Date of Your Injury/Accident *

Your Auto Claim # *

Your Claim Adjusters Full Name *

Your Claim Adjusters Phone *

You chose to upload images. You'll need your insurance card to complete this section.

Upload (2) clear pictures of your health insurance card, one of the front and one of the back of your card.

File Upload: Health Insurance Card (Front & Back) - Has Primary Insurance Only

Click or drag files to this area to upload. You can upload up to 2 files.

You chose to upload images. You'll need your insurance cards to complete this section.

Primary Insurance Card

Upload (2) clear pictures of your Primary health insurance card here, one of the front and one of the back of your card.

File Upload: Primary Health Insurance Card (Front & Back) - Has Secondary Insurance

Click or drag files to this area to upload. You can upload up to 2 files.

Supplemental Health Insurance Card

Upload (2) clear pictures of your Secondary health insurance card here, one of the front and one of the back of your card.

File Upload: Secondary Health Insurance Card (Front & Back) - Has Secondary Insurance

Click or drag files to this area to upload. You can upload up to 2 files.

3. Submit Insurance Information (Continued)

Is the insurance policy under your name? *

Is the insurance policy holders name listed on the card? *

Subscribers Full Name *

First

Last

Subscribers Full Name *

First

Last

Subscriber's DOB *

3. Submit Insurance Information (Continued)

Supplemental Health Insurance Information

Using your supplemental/secondary health insurance card, complete the fields below.

Your Full Legal Name *

First

Last

Is the supplemental insurance policy under your name? *

Is the supplemental insurance policy holders name listed on the card? *

Subscribers Full Name *

First

Last

Subscribers Full Name *

First

Last

Subscriber's DOB *

3. Submit Insurance Information (Continued)

Enter Workman's Compensation Insurance Information

Date of Your Injury/Accident *

3. Submit Insurance Information (Continued)

Enter Auto Insurance Information

Date of Your Injury/Accident *

3. Submit Insurance Information (Continued)

For this next section, use your Health Insurance Information to answer the questions below.

Your Full Legal Name *

First

Last

Is your Health Insurance policy under your name? *

Is the supplemental insurance policy holders name listed on the card? *

Subscribers Full Name *

First

Last

Subscribers Full Name *

First

Last

Subscriber's DOB *

3. Submit Insurance Information (Continued)

To ensure we have accurate information to retrieve your benefits, please answer a few questions:

Is the insurance policy under your name? *

Is your Health Insurance policy holders name listed on the card? *

3. Submit Insurance Information (Continued)

We'll need a few more pieces of information to retrieve your insurance benefits. Use your Primary/Main Health Insurance card to answer a few questions below.

Is the insurance policy under your name? *

Is the insurance policy holders name listed on the card? *

Your Full Legal Name *

First

Last

Your Date Of Birth *

What is the Subscribers Legal Full Name? *

First

Last

Subscriber's date of birth *

We will need the subscribers date of birth to retrieve health insurance benefit information from your insurance.

3. Submit Insurance Information (Continued)

Member/Enrollee ID *

Usually listed on front of your insurance card.

Group Number

Insurance Providers/Customer Service Phone (Usually listed on back of your insurance card) *

Usually the provider or customer service number is listed on the back of your insurance card.

3. Submit Insurance Information (Continued)

Member/Enrollee ID *

Usually listed on front of your insurance card.

Group Number

Insurance Providers/Customer Service Phone (Usually listed on back of your insurance card) *

Usually the provider or customer service number is listed on the back of your insurance card.

3. Submit Insurance Information (Continued)

Almost done! We'll need a few more pieces of information to retrieve your insurance benefits.

Your Full Legal Name *

First

Last

Your Date Of Birth *

What is the Subscribers Legal Full Name? *

First

Last

Subscriber's date of birth *

We will need the subscribers date of birth to retrieve health insurance benefit information from your insurance.

3. Submit Insurance Information (Continued)

Next, answer the same questions about your Supplementary Health Insurance card to answer a few questions below.

Is the insurance policy under your name? *

Is the insurance policy holders name listed on the card? *

What is the Subscribers Legal Full Name? *

First

Last

What is the Subscribers Legal Full Name? *

First

Last

Subscriber's date of birth *

We will need the subscribers date of birth to retrieve health insurance benefit information from your insurance.

3. Submit Insurance Information (Continued)

Enter Workman's Compensation Insurance Information

Your Workers Comp Claim # *

Your Claim Adjusters Full Name *

Your Claim Adjusters Phone *

3. Submit Insurance Information (Continued)

Enter Auto Insurance Information

Your Auto Claim # *

Your Claim Adjusters Full Name *

Your Claim Adjusters Phone *

3. Submit Insurance Information (Continued)

Enter Health Insurance Information

What is the Subscribers Legal Full Name? *

First

Last

What is the Subscribers Legal Full Name? *

First

Last

Subscriber's date of birth *

We will need the subscribers date of birth to retrieve health insurance benefit information from your insurance.

Member/Enrollee ID *

Usually listed on front of your insurance card.

Group Number

Insurance Providers/Customer Service Phone (Usually listed on back of your insurance card) *

Usually the provider or customer service number is listed on the back of your insurance card.

4. Contact Information

Complete a few more questions and submit the form below.

Are you a past customer of Borja Physical Therapy? *

Welcome! How did you hear about us? *

Welcome back! How were your reminded of us this time around? *

When are you anticipating to start physical therapy? *

Immediately
Within 1 Week
Within 2-4 Weeks
Within 1-3 Months
>3 Months

Phone *

We'll reach out to you once we have your insurance benefits. We'll always leave a voicemail if have trouble reaching you.

We'll always attempt to contact you by phone first, but if we are unable to reach you by phone or leave a voicemail, we'll attempt email.

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