Health Insurance Resubmission
Please submit the health insurance information that was active for the dates of service.
Full Name of Test Recipient
*
First Name
Middle Initial
Last Name
Test Recipient's Date of Birth
*
-
Month
-
Day
Year
Date
Health Insurance Provider or Plan Name
*
Insurance Policy/ID Number
*
Group Number
Is the Test Recipient the primary insurance holder?
*
Yes
No
Test Recipient's Relationship to Insured
*
Self
Spouse
Child
Other
Full Name of Insurance Policy Holder
*
First Name
Middle Name
Last Name
Insured's Sex
*
Male
Female
Insured's Date of Birth
*
-
Month
-
Day
Year
Date
Fields marked with * are required.
Insurance Policy Holder Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Submit
Should be Empty: