Name: Spokane Rehab & Pain Clinic
Address: 1315 N. Division, Spokane, WA, 99202
Telephone: 509-808-6265

Insurance Information
Patient Name*
First Last
Patient Date of Birth*
Date Format: MM slash DD slash YYYY
Policy Holder's Name*
First Last
Policy Holder's Date of Birth*
Date Format: MM slash DD slash YYYY
Primary Insurance Company*
If you're a private pay patient, please enter "private pay"
Primary Insurance Policy Number
"Provider" Phone Number - primary insurance
Please look on the back of your health insurance card and enter the phone number specified for providers.
Secondary Insurance Company
Secondary Insurance Policy Number
Patient Contact Information
Patient Phone Number*
Patient Email*
Patient Address*
Street Address Address Line 2 City State ZIP Code