Insurance Update
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Zip code that insurance company has on file for primary subscriber
*
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 zip code
*
Your relationship to primary prescriber
If it's you write "Self"
Date New Insurance Began
*
-
Month
-
Day
Year
Date
What is the new insurance?
*
BCBS PPO
Blue Care Network
Aetna (we are out of network but will attempt to send claims on your behalf for out of network coverage)
Priority Health (we are generally out of network except Dr. Kumar)
Cigna (we are out of network but will attempt to send claims on your behalf)
UHC (we are out of network, we have been told prior authorization is required to utilize your out of network benefits, we will attempt to send claims on your behalf
HAP (we are out of network but will attempt to send claims on your behalf)
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?
*
BCBS PPO
Blue Care Network
Aetna (we are out of network but will attempt to send claims on your behalf for out of network coverage)
Priority Health (we are generally out of network except Dr. Kumar)
Cigna (we are out of network but will attempt to send claims on your behalf)
UHC (we are out of network, we have been told prior authorization is required to utilize your out of network benefits, we will attempt to send claims on your behalf
HAP (we are out of network but will attempt to send claims on your behalf)
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: 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
Should be Empty: