Insurance Card Submission Form

Insurance Card Submission Form

Integrated Behavioral Care of New England, LLC
Date

MonthDayYear
Date
Client's Full Name*

First NameLast Name
Date of Birth*
Important Notice: Due to contracting issues with the insurance company, we are no longer accepting Carelon Insurance (includes: Fallon, MBHP, Unicare, Wellsense, Wellfleet) effective 1/1/2025.
Primary Insurance

Please Note: We are NOT currently participating providers with MassHealth
Insurance Company*
Insurance ID (include any letters and numbers)*
Who is the primary subscriber of this insurance?*

SelfSpouse or partnerParent / Legal GuardianGrandparent or Family MemberOther
Primary Subscriber's Name

First NameLast Name
Subscriber's DOB
Insurance Card:

We know this is a little tricky...Position the card so that it is close enough to fill most of the screen and straight as possible. Make sure the lighting is good, and watch your fingers!
Please take a picture of the FRONT of the card*
Please take a picture of the BACK of the card*
Secondary Insurance

Please Note: We are NOT currently participating providers with MassHealth
Does the client have secondary insurance?

NoYesYes - MassHealth (I understand IBC is not participating with MassHealth and I am responsible for my copays)
Insurance Company
Insurance ID (include any letters and numbers)
Who is the primary subscriber of this insurance?

SelfSpouse or partnerParent / Legal GuardianGrandparent or Family MemberOther
Primary Subscriber's Name

First NameLast Name
Subscriber's DOB
Insurance Card:

We know this is a little tricky...Position the card so that it is close enough to fill most of the screen and straight as possible. Make sure the lighting is good, and watch your fingers!
Please take a picture of the FRONT of the card*
Please take a picture of the BACK of the card*
Integrated Behavioral Care makes every effort to provide the most up to date information the insurance company has regarding member eligibility and benefits. However, we cannot guarantee that the information has not changed, was given incorrectly, or will not change since being obtained. The information obtained from the member's insurance company is not a guarantee of payment. Benefits are subject to eligibility at the time of service and all plan conditions, limitations and exclusions. We encourage all clients to verify their eligibility and benefits information with their insurance company as well.
Should be Empty:

Insurance Card Submission Form

Primary Insurance

Secondary Insurance