Insurance Update
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Select the state for which you are scheduling with Ann Arbor Psych
Michigan
Pennsylvania
In how many days is your next appointment? (so we can triage this)
Less than 24 hours
24-72 hours
3-7 days
More than 7 days
Number
Zip code that insurance company has on file for PRIMARY subscriber
*
The primary subscriber may not be you! We'll ask for more info later in the form
Address of the PRIMARY subscriber that insurance has on file
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
New Insurance Information
Who is the primary subscriber to this insurance?
*
I am the primary subscriber
Someone else is the primary subscriber
Primary Subscrber
First Name
Last Name
Primary Subscriber Date of Birth
-
Month
-
Day
Year
Date
Primary Subscriber's Sex
*
Primary subscriber zip code
*
Your relationship to primary prescriber
Select one: Patient is subscriber, Patient is spouse of subscriber, Patient is child of subscriber, Patient is other dependent of child, Patient is adult dependent of subscriber
Date New Insurance Began
*
-
Month
-
Day
Year
Date
What is the new insurance? (MI)
*
BCBS PPO/BCBS FEP (All Providers are In-Network)
Blue Care Network (All providers are in-network except Ben Hadden and Rachel Thompson)
Blue Cross Complete (All Providers are In-Network)
Medicare Plus Blue (Dr. Akash Kumar, NP Brain Phillips, Kristen Daniels, and PA Roopa Kline are In-Network)
Aetna (All providers are in-network except Kristen Daniels and Pamela Aalto. We will attempt to send Out-of-Network Claims)
Priority Health (All providers are in-network except Ben Hadden, Kristen Daniels, Pamela Aalto, Sarah Kruger, and Rachel Thompson)
Cigna (Dr Akash kumar is In-Network while all the other providers are Out-Of-Network, and we will attempt to send Out-of-Network Claims)
UHC (All providers are in-network except Ben Hadden and Rachel Thompson)
HAP/ASR (We will attempt to send Out-of-Network Claims)
Medicare of MI (All providers are in-network except Rachel Thompson and Ben Hadden who cannot take Medicare patients)
Carelon/Beacon (We will attempt to send Out-of-Network Claims)
Tricare (We will attempt to send Out-of-Network Claims)
Magellan (We will attempt to send Out-of-Network Claims)
McLaren (Dr. Akash Kumar and PA Bruce Burkeen are in-network. We are currently enrolling other providers)
McLaren Medicaid (Dr. Akash Kumar is in-network)
Medicaid of MI (Dr. Kumar, NP Brian Phillips, NP Anthonia Umelogu, Dr. Sedlar, Kristen Daniels LMSW, PA Austin Powell, PA Bruce Burkeen, PA Angela Braun and Mary Jameson LMSW are in-network)
Aetna Better Health of MI (All providers are In-Network except Pamela Aalto, Sarah Kruger and Kristen Daniels)
First Health Network (All providers are in-network except for Kristen Daniels, Sarah Kruger and Pamela Aalto)
North Carolina State Health Plan (All providers are in-network except for Kristen Daniels, Sarah Kruger and Pamela Aalto)
Meridian Medicaid/Ambetter/Merididan Marketplace/Wellcare (All providers are In-Network)
Other (Please advise below)
What is the new insurance? (PA)
*
BCBS Independence (All Providers are In-Network)
Capital Blue Cross (All providers are In-Network)
BCBS Keystone (All providers are In-Network)
Blue Cross Complete (All Providers are In-Network)
BCBS Highmark (All Providers are In-Network)
Cigna (We will attempt to send Out-of-Network Claims)
Carelon/Beacon (We will attempt to send Out-of-Network Claims)
Other (Please advise below)
Insurance ID + Customer Service number on back of card
*
Previous Insurance
What was your previous insurance?
What date did previous insurance end?
-
Month
-
Day
Year
Date
Anything else we need to know?
Take a photo of the FRONT of your insurance card. "RETAKE photo" does not work on laptops. If your picture came out wrong the first time, email it to: insuranceinquiries@annarborpsych.mojohelpdesk.com
Take a photo of back of your insurance card. "RETAKE photo" does not work on laptops. If your picture came out wrong the first time, email it to: insuranceinquiries@annarborpsych.mojohelpdesk.com
Secondary Insurance
Is there a secondary insurance that terminated?
No
Yes
SECONDARY INSURANCE: What secondary insurance and which date did it terminate?
Is there secondary insurance being added?
*
No
Yes
SECONDARY INSURANCE: What date does or did it start?
*
-
Month
-
Day
Year
Date
What is the new secondary insurance (MI)?
*
BCBS PPO/BCBS FEP (All Providers are In-Network)
Blue Care Network (All providers are in-network except Ben Hadden and Rachel Thompson)
Blue Cross Complete (All Providers are In-Network)
Medicare Plus Blue (Dr. Akash Kumar, NP Brain Phillips, Kristen Daniels, and PA Roopa Kline are In-Network)
Aetna (All providers are in-network except Kristen Daniels and Pamela Aalto. We will attempt to send Out-of-Network Claims)
Priority Health (All providers are in-network except Ben Hadden, Kristen Daniels, Pamela Aalto, Sarah Kruger, and Rachel Thompson)
Cigna (Dr Akash kumar is In-Network while all the other providers are Out-Of-Network, and we will attempt to send Out-of-Network Claims)
UHC (All providers are in-network except Ben Hadden and Rachel Thompson)
HAP/ASR (We will attempt to send Out-of-Network Claims)
Medicare of MI (All providers are in-network except Rachel Thompson and Ben Hadden who cannot take Medicare patients)
McLaren (Dr. Akash Kumar and PA Bruce Burkeen are in-network. We are currently enrolling other providers)
McLaren Medicaid (Dr. Akash Kumar is in-network)
Carelon/Beacon (We will attempt to send Out-of-Network Claims)
Tricare (We will attempt to send Out-of-Network Claims)
Magellan (We will attempt to send Out-of-Network Claims)
Medicaid of MI (Dr. Kumar, NP Brian Phillips, NP Anthonia Umelogu, Dr. Sedlar, Kristen Daniels LMSW, PA Austin Powell, PA Bruce Burkeen, PA Angela Braun and Mary Jameson LMSW are in-network)
Aetna Better Health of MI (All providers are In-Network except Pamela Aalto, Sarah Kruger and Kristen Daniels)
First Health Network (All providers are in-network except for Kristen Daniels, Sarah Kruger and Pamela Aalto)
North Carolina State Health Plan (All providers are in-network except for Kristen Daniels, Sarah Kruger and Pamela Aalto)
Meridian Medicaid/Ambetter/Merididan Marketplace/Wellcare (All providers are In-Network)
Other (Please advise below)
What is the new secondary insurance (PA)?
*
BCBS Independence (All Providers are In-Network)
Capital Blue Cross (All providers are In-Network)
BCBS Keystone (All providers are In-Network)
Blue Cross Complete (All Providers are In-Network)
BCBS Highmark (All Providers are In-Network)
Cigna (We will attempt to send Out-of-Network Claims)
Carelon/Beacon (We will attempt to send Out-of-Network Claims)
Other (Please advise below)
Insurance ID + Customer Service number on back of card
*
SECONDARY INSURANCE: Primary Subscriber (if different from patient)
First Name
Last Name
SECONDARY INSURANCE: Date of Birth of Primary Subscriber (if different from patient)
-
Month
-
Day
Year
Date
SECONDARY INSURANCE: Subscriber's Sex (if different from patient)
SECONDARY INSURANCE: Zip code of primary subscriber (if different from patient)
SECONDARY INSURANCE: Take a picture of the front of your card. "RETAKE photo" does not work on laptops. If your picture came out wrong the first time, email it to: insuranceinquiries@annarborpsych.mojohelpdesk.com
SECONDARY INSURANCE: Take a picture of the BACK of your card. "RETAKE photo" does not work on laptops. If your picture came out wrong the first time, email it to: insuranceinquiries@annarborpsych.mojohelpdesk.com
Submit
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