Home - Sophit4You Wellness

First Name

Last Name

Email

Are you the primary insured/policy holder?

Yes

No

Date of Birth

Phone/Mobile

First Name of Primary Insured

Last Name of Primary Insured

Primary Insured Date of Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Insurance Provider / Company Name

Member ID / Policy Number

Upload Front of Insurance Card

Choose File

Group Number (if applicable)

Plan Type

Upload Back of Insurance Card

Choose File

Other

How many sessions would you be able to commit to in a six-week program?

If Maybe, Please Explain

Which session format do you prefer?

Virtual

In-Person

Both

Consent & Acknowledgement

I authorize SoPHIT4you, LLC to verify my insurance benefits for this program.

I understand registration is not confirmed until my coverage is verified and any required copay is paid.

I understand that if my insurance does not cover this service, I am responsible for payment

Insurance Registration Form