Full Name
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Date of Birth
*
Phone Number
*
Email Address
*
Mailing Address
*
Insurance Provider
*
Cigna In-Network
UnitedHealthCare (UHC) In-Network
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Primary Subscriber Name
*
Primary Subscriber Date of Birth
*
Front of Insurance Card - Email to Admissions@balancedtx.com
Back of Insurance Card - Email to Admissions@balancedtx.com
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