IF YOU HAVE INSURANCE, PLEASE FILL OUT THE BELOW. IF YOU DO NOT HAVE INSURANCE, SKIP THIS. THANKS!
I understand that Dr. Neely is an out of network provider, and I will owe the difference of what the insurance reimburses.
Primary Insurance Company
Subscriber ID #
If your subscriber ID is different from the policy holder's ID, please provide the #
Policy Holder's Name
Policy Holder's Birthdate
Policy Holder's Social Security #
Policy Holder's Employer
Should be Empty:
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