zPods Pre-Authorization Form We’ll contact your insurance provider for pre-authorization and billing. (Applicant) Child's Name * First Name Last Name (Guardian) Email * (Guardian) Phone (###) ### #### (Applicant) Child's Date of Birth * MM DD YYYY Policy Holder Name * First Name Last Name Policy Holder Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Is your insurance plan part of Medicaid or Medicare? * Yes No Is TRICARE your Primary Insurance? * Yes No Insurance Carrier * Insurance ID * Insurance Group Thank you!
