Skip the hold music, we'll call your insurance for you!

Fill out this quick form, and we'll provide a quote of coverage within 48 business hours.

The more info you share, the faster and more accurate we can confirm your benefits.

Policy Info

Insurance Company (from your card) *

Member ID (from your card) *

Group Number (if listed)

Upload Front of Card (saves time + prevents errors)

Front

Upload Back of Card (so we can contact them directly)

Back

Who is the policy holder? *

It's me (I'm the policy holder)

It's someone else (spouse/parent)

Policy Holders First and Last Name

Policy Holder's Gender

Policy Holders Date of Birth

Patient's Details

Patient's First Name *

Patient's Last Name *

Date of birth *

Patient's Height *

Patient's Weight *

State of Residence *

What Do You Want Your Dietitian to Focus On?

Choose the areas that best match your goals and lifestyle.

Performance

CrossFit Competitive

CrossFit Casual / General Fitness

Lifestyle

Macros & Meal Planning

Supplements

Emotional Eating

Body Composition Goals

Lean Out (Fat Loss)

Build Muscle Mass & Strength

Body Recomposition (Lose Fat, Keep/Gain Muscle/Strength

Health & Recovery

Hormones & Women’s Health

Gut Health

GLP-1 Weight Loss Medications (Monjaro, Ozempic, Wegoovy)

Sleep & Recovery

Insurance Conditions

Check all that apply (helps us confirm your coverage)

Weight Management / General Health

General Healthy Diet (Z71.3)

Overweight BMI 25-29 (E66.3)

Inappropriate Diet and Eating Habits (Z72.4)

Obese BMI 30+ (E66.9)

Heart / Kidney Health

High Cholesterol (E78.00)

High Blood Pressure / Hypertension (i10)

Family History of Heart Disease (Z82.49)

Chronic Kidney Disease (N18.9)

Blood Sugars / Diabetes

Eating Disorders

Anorexia (R63.0)

Binge Eating Disorder (F50.81)

Bulimia (F50.2)

Location Preference

Anything else we need to know?

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This is a free, no obligation.

We'll verify your benefits as accurately as possible, but final coverage is determined by your insurance provider.

Any unpaid claims remain the patient's responsibility.

Contact Us

TEXT: 469-300-1392