Insurance

Let us check your coverage.

Send your plan details and we'll confirm your benefits before your visit — usually within one business day.

Section A · You

First name

Last name

Date of birth

Phone

Are you a current patient?

Section B · Your plan

Carrier

Member ID

Group number (optional)

Are you the policyholder?

What visit are you checking coverage for?

What is the visit for? (optional)

Anything else we should know? (optional)

Insurance card photos

Insurance card — front

JPG, PNG, or PDF · up to 10 MB

Insurance card — back

JPG, PNG, or PDF · up to 10 MB

Your card images are sent securely to the office and are only used to verify your benefits.

I authorize Dr. A. Shamani, Inc. to contact my insurance plan to verify my benefits.

Yes, email me about my appointment and care.

By checking this box, I agree to receive text messages from Azam Shamani, MD about my appointment and care. Msg & data rates may apply. Reply STOP to opt out, HELP for help.

This form is not for medical emergencies. If this is an emergency, call 911.

Your information is transmitted securely and used only to verify your coverage.