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Insurance Authorization Form

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Primary Insurance Information

Name of Insurance Company

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(found on the back of the card)

Policy #

Group/Plan #

Primary Cardholder's First Name

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Relationship to Patient

Primary Cardholder's Employer

Co-Morbid Conditions

Co-Morbid Conditions
(please check all that apply)
Asthma Depression GERD/Heartburn High Cholesterol Hyperlipidemia (high triglycerides) Hypertension/High Blood Pressure Sleep Apnea Osteoarthritis Pseudotumor Cerebri Swelling of the legs (Edema) Type 2 Diabetes Urinary Stress Incontinence

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5820 Lamar Avenue
Suite #200
Mission, KS 66202
Phone: 913-492-2530
Fax: 913-492-2576

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