We work with leading insurance providers. Fill out the form below to find out if your insurance company will cover your treatment costs at Restore, Incorporated. Get Your Insurance Card You will need it to complete this form. Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Patient Relationship *Patient Relationship (*)I'm the patientI'm the patient's spouseI'm the patient's motherI'm the patient's fatherI'm the patient's sisterI'm the patient's brotherI'm the patient's childI'm the patient's other relativePolicy Holder's Information *Primary Insured Name *Primary Insured Name (copy) *Primary Insured Name (copy) (copy) *Patient Information *FirstLastPhone Number (*) *Insurance Information *Patient's Date of Birth *Insurance Phone Number *Insurance ID Number *Group ID Number *Insurance Plan Type *Insurance Type (*)EPO PlanHMO PlanPOS PlanPPO PlanOther PlanAdditional InformationSubmit