Health Insurance Form

Health Insurance Resubmission

Please submit the health insurance information that was active for the dates of service.
Full Name of Test Recipient*

First NameMiddle InitialLast Name
Test Recipient's Date of Birth*

MonthDayYear
Date
Health Insurance Provider or Plan Name*
Insurance Policy/ID Number*
Group Number
Is the Test Recipient the primary insurance holder?*

YesNo
Test Recipient's Relationship to Insured*

SelfSpouseChildOther
Full Name of Insurance Policy Holder*

First NameMiddle NameLast Name
Insured's Sex*

MaleFemale
Insured's Date of Birth*

MonthDayYear
Date
Fields marked with * are required.
Insurance Policy Holder Address*

Street Address

Street Address Line 2

CityState

Zip Code
Should be Empty:

Health Insurance Resubmission