Please use the form below to submit the required information for verification of benefits purposes only. If you have any questions about this information, please reach out to our insurance team at insurance@michicare.org or 517.619.1290.
Clinic Name:
*
This is the name of the clinic submitting the information.
What type of verification is this?
*
New Patient
Returning Patient / New Injury
Current Patient - New Insurance
Patient Name:
*
Example: John B. Citizen
Patient Date of Birth:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Example: 03/24/1997
Primary Insurance:
*
Examples: BCBSM, BCN, Cigna, Priority, etc.
Policy ID:
*
PRIMARY POLICY ID
Policy Group:
*
Other Insurance Coverages & ID #:
Example: Priority ID# 8675309
Date of Next Appointment
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Is this a same day/urgent patient? If yes, please include time of appointment in next field.
*
Yes
No
If same day/urgent, please include time of appointment:
Hour Minutes
AM
PM
AM/PM Option
Name of provider seeing patient:
This information may be helpful when verifying patient benefits.
If patient is a dependent, please input name of policy holder:
Example: John C. Citizen
Insurance Carrier Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
If patient is a dependent, please input policy holder DOB:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Example: 09/22/1971
Clinic Email:
Please enter an email if you would like to receive a receipt of submission.
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