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*
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Policy Holder's Name*
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Policy Holder's Date of Birth*
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Primary Insurance Company*

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Primary Insurance Policy Number
"Provider" Phone Number - primary insurance
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Secondary Insurance Company
Secondary Insurance Policy Number
Patient Contact Information
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Patient Email*
Patient Address*
Street Address Address Line 2 City State ZIP Code