INSURANCE CARDS AND PHOTO ID

Shelby Counseling Associates, PSC
12701 Townepark Way Louisville, KY 40243

Phone: 502-254-8880 Fax: 502-254-8870
SCA@ShelbyCounseling.com
Client Name:*

First NameLast Name
Client DOB:*

MonthDayYear
Date
Primary Insurance MEMBER ID/Policy Number*
Primary Insurance Subscriber Name*

First NameLast Name
Relationship to Patient*
Subscriber DOB:*

MonthDayYear
Date
Subscriber SSN:*
Subscriber Employer:*
Do you have a secondary insurance?*

YesNo
Secondary Insurance MEMBER ID/Policy Number
Secondary Insurance Subscriber Name

First NameLast Name
Relationship to Patient
Subscriber Date of Birth:

MonthDayYear
Date
Subscriber SSN
Subscriber Employer