Insurance Card Picture Submission

1
Patient Name* This field is required.
First Name
Last Name
2
Patient's Date of Birth* This field is required.
Month
Day
Year
3
Insurance Carrier* This field is required.If your Mental Health coverage is through a third party payer, please select them as your main insurance carrier
Aetna
Alignment Healthcare
Blue Cross Blue Shield
Cigna Healthcare (including Cigna Behavioral Health, Cigna Medicare, & Evernorth)
Humana
Magellan
Medcost
Medicare
United Healthcare (including UBH, UMR, Golden Rule, Oxford Health, Optum, etc.)
Supplemental Insurance to Medicare (Plan D-N)
Other
Please note, that if you select Other, your insurance plan might not be in network with your provider
4
Please enter your insurance member ID number (including person # if any), group number, and effective date this policy began* This field is required.
Member ID
Group #
Effective Date of Policy
5
Subscriber / Policy Holder's Information* This field is required.Please provide the policy holder's name, date of birth, address, social security #, and relationship to patient
Subscriber's First and Last Name
Subscriber's Date of Birth
Please Select
Please Select
Self
Spouse
Domestic Partner
Mother
Father
Grandparent
Step-parent
Other
Relationship to Patient
Social Security number
Subscriber's Address
6
Upload Pictures of the Front & Back of your Insurance CardIf you cannot upload here, please email pictures to insurance@peacepsychiatry.com
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
You can upload multiple files if needed
Cancelof
7
Front of Card -- MAKE SURE PICTURE IS CLEAR (you should see a preview here)* This field is required.
Should be Empty: