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Any information you share with me will be kept in total confidence. My practice is HIPAA compliant and all communications with me are secure.

Please complete the following form so we can verify your insurance coverage.

After clicking “Submit” below Janis will receive an email notification with your insurance information for verification. Someone will be in contact with you as soon as possible. Thanks.


Name *
Name
Address *
Address
Date of Birth *
Date of Birth
Phone
Phone