Let’s Start the Coverage Process

I want to try to get Encala covered through my health insurance plan.

By providing the information below, I am asking the Encala support team to begin the coverage investigation process.

Patient Name(Required)

Parent/Guardian Name

Relationship to Patient

Patient Gender(Required)

Patient DOB(Required)

Patient or Parent / Guardian Email(Required)

Phone Number(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Insurance Provider(Required)

Insurance ID(Required)

Group Number(Required)

Healthcare Professional or Office Contact Person Name(Required)

Healthcare Professional or Office Contact Person Email Address

Healthcare Professional or Office Contact Person Phone Number(Required)

Medical Center(Required)

Medical Center City(Required)

Medical Center State(Required)