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To confirm if our service is covered by your insurance or just need more information, you may contact us by filling out the form below. *APG accepts most insurance plans. If you would like us to confirm which benefits are accepted by your insurance plan, please fill out the form below. We will contact you to discuss what is covered.

CONTACT INFO

Name

First Name

Last Name

Email Address

Phone

Enter a phone number for a confirmation phone call and/or text message.

(###)

###

####

Preferred method of Contact

HOW CAN WE HELP?

Chief Complaint or Primary Diagnosis

Service Interested In

Additional Comments

INSURANCE INFO

Insurance Carrier

Select your insurance carrier

Insurance Company Phone Number (from back of card)

Relationship to Insured

Date of Birth

YYYY

Gender

Group Number

Member Number

Claim # if an accident

*Medicare does not cover any of our services.