Insurance

I am no longer accepting insurance. However, I do provide superbills which can be submitted to your insurance provider for partial or full reimbursement.

Name

First Name

Last Name

Email

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of birth

MM

DD

YYYY

Insurance provider name

Insurance Group #

Insurance ID #

Social

Privacy

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4.