Verification Of Benefits Form

Client's Full Legal Name *

Date of birth *

Phone *

Email *

Reason for VOB Request

Insurance Information

Front Of Insurance Card *

Click upload button first, do not drag and drop

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Back Of Insurance Card *

Click upload button first, do not drag and drop

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Secondary Insurance Information

Front Of Secondary Insurance Card

Upload if you have secondary insurance

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Back Of Secondary Insurance Card

Upload if you have secondary insurance

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

UCSB CAPS Referral

Upload your CAPS referral here. If you have UCSHIP a referral is required for services.

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF