New Client Application Form
Please fill out this form completely.
Lincoln or Yuba City Office
Lincoln, CA Office
898 5th street, Suite B. Tuesday and Thursday
Yuba City Office
1634 Poole Blvd, Suite 400. Inside Allstate office. Wednesday
If client is a minor please state their age.
Insured persons name, if different than client
Insured person's ID number
name of company, authorization number, claims address, Insured ID number if not listed above.
Insurance Authorization Number
Claims Address for Insurance Billing, (not the one on your card)
Your best contact email address
Your best contact Phone Number
Issues to be addressed
Best time of day for appointment-
Lincon Office hours on Tuesday and Thursday.
Yuba City Office hours Wednesdaiy
All prices in US Dollars
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