Insurance Card Picture Submission Form

1
Are you a New or Established Patient?
New Patient
Established Patient
2
Since when do you have this new insurance? (aprox date is ok)
3
ALL PATIENTS PLEASE READ

MEDICARE PATIENTS: If you have a SUPLEMENTAL PLAN, please note we do not send plans to secondary insurances. You must have coordination of benefits with Medicare, if so, your Medicare will "cross over" the claim to your secondary plan.

COMMERCIAL PLANS: Please note that we file with primary insurance only. If you have more than one insurance, you must have coordination of benefits in place. We do not file secondary insurance claims.

OUT OF NETWORK PLANS: We are not in network with the below plans and do not file out of network. we can still see you as a patient, however, you will be a Self Pay patient

Carolina Behavioral Health Alliance (Medcost carved out mental health benefits)

Bright Health

Multiplan

Meritain Health

Tricare

Magellan

VA insurance

Wellcare

If you have Medicaid or have a Medicaid sponsored plan, we can not see you as we are out of Network, furthermore, pharmacies will not fill prescriptions written by non Medicaid providers. These are some common Medicaid sponsored plans:

Healthy Blue - BCBS Medicaid Sponsored - NCHHS

Carolina Complete Health - Medicaid sponsored plan.

Medicaid as Secondary or Suplement

By continuing you have read and agree to the above.
4
Name of Insurance Carrier* This field is required.
Please Select
Please Select
Aetna
Ambetter
Blue Cross Blue Shield
Cigna
Humana
Medcost
Medicare
UMR
United
Other Not listed
5
Patient Name (IF PATIENT IS A CHILD, WRITE THE CHILD'S NAME)* This field is required.
First Name
Last Name
6
Patient's Date of Birth* This field is required.
Month
Day
Year
7
What insurance is this?* This field is required.Please read our policies regarding claims on who we bill. Raleigh Wellness Behavioral Health only bills primary insurance.
Primary medical coverage
Secondary medical coverage
Only Prescription coverage
I don't know
8
Is the patient the primary policy holder on this insurance?* This field is required.
YESNO
9
Primary Policy Holder Name* This field is required.
First Name
Last Name
10
Policy Holder Relationship to Patient * This field is required.
Please Select
Please Select
Spouse
Parent
Other
11
Primary Policy Holder Date of Birth* This field is required.
Month
Day
Year
12
Primary Policy Holder Sex* This field is required.
Female
Male
13
Policy number or Subscriber ID (policy number)* This field is required.
14
Insurance Phone Number (back of the card)* This field is required.
Please enter a valid phone number.
15
Date
Date
Month
Day
Year
16
Insert a picture of the FRONT of your card. ENSURE ITS A CLOSE UP PICTURE* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
17
Insert a picture of the BACK of your card. * This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
18
Insert a picture of your (or Parent) ID/Driver LicenseMust have a valid NC ID to be a patient.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
Should be Empty: