Insurance Form

PMR Accepts Most Major Private Insurance plans. We are unable to accept Medicare, Medi-Cal, Tri-Care or similar Government Programs. Insurance Inquiry Direct Line at Facility 619.363.4PMR (4767)…..FAX 619.655.4762

Patient Name

PT DOB

PT Address

State

E-Mail

Insurance Co Phone

Insured DOB

Plan Type HMOPPOEPONot Sure


Group #

Policy Effective Date

Describe PT Current Condition/Need Help or Intervention?


(619) 363-4767
Previous Next
Close
Test Caption
Test Description goes like this