Insurance Info | Hey Gurl Hair Comp 2

top of page

Home
Insurance Info
About April
Hey Gurl University
Medical Wigs
Appointments
Budget Friendly Wigs
c11c4030-ee60-4d35-96a2-8847907cf04b
Hair & Wig Products
0077d069-7a8e-4b87-9bc9-093ee3eaad39

Health Insurance Verification

Please note: Submitting this form does not guarantee coverage or payment. Benefits are determined by your specific insurance plan, eligibility, medical necessity, and may be subject to authorizations, deductibles, copays, coinsurance, and plan limits.

Client First name*

Client Last name*

Email*

Phone*

Birthday*

Month

Day

Year

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Please select one*

Self-Pay Client

Insurance Client

Veteran / VA

Other

Relationship to Client*

Reason For Hair *

Alopecia

Cancer Treatment

Lupus

Burns

Medical Condition

Medical Related

Other

Insurance Company Name*

Member/Subscriber ID*

Group number*

Last 4 SSN*

Insurance company customer-service/provider-services phone number (if shown on card)*

Upload front and back of insurance card*

Option 1

Option 2

Authorization to Verify Insurance Benefits I authorize Hey Gurl Hair Company LLC to contact my insurance company for the purpose of verifying my eligibility, benefits, coverage requirements, authorization requirements, and reimbursement information relate*

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date Signed*

Month

Day

Year

Privacy Notice: Please only submit information required for insurance verification. Hey Gurl Hair Company LLC handles all patient data in accordance with our privacy practices. Final coverage and benefit decisions are made solely by your insurance carrier and are not guaranteed by Hey Gurl Hair Company LLC.

bottom of page