Verification Of Benefits Form
Client's Full Legal Name
*
Date of birth
*
Phone
*
Email
*
Reason for VOB Request
New Client
Existing Client with Insurance Changes
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Insurance Information
Front Of Insurance Card
*
Click upload button first, do not drag and drop
Back Of Insurance Card
*
Click upload button first, do not drag and drop
Secondary Insurance Information
Front Of Secondary Insurance Card
Upload if you have secondary insurance
Back Of Secondary Insurance Card
Upload if you have secondary insurance
UCSB CAPS Referral
Upload your CAPS referral here. If you have UCSHIP a referral is required for services.
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