Insurance Verification Form

1
Prospective Patient Name
First Name
Last Name
2
Name of Individual Completing FormIf different from prospective patient.
First Name
Last Name
3
Prospective Patient Date of Birth
Date
Year
Month
Day
4
Insurance Provider
Blue Cross Blue Shield of Michigan (we cannot verify out of state plans)
BCN
PHP/UofM Health Plan
Priority Health
Aetna
Cigna
5
Member IDPlease include the alphanumeric prefix.
6
Subscriber Name
First Name
Last Name
7
Subscriber Date of Birth
Date
Year
Month
Day
8
Please upload the front and back of your insurance card. (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
9
EmailPlease provide an email where we should send our results.
example@example.com
10
Name of Counselor (if known)
First Name
Last Name
Should be Empty: