Insurance Card Submission Form
Well Behavioral Health, LLC
Date
-
Month
-
Day
Year
Date
Client's Full Name
*
First Name
Last Name
Date of Birth
*
Email
*
example@example.com
Who is the primary subscriber of this insurance?
*
Self
Spouse or partner
Parent / Legal Guardian
Grandparent or Family Member
Other
Primary Subscriber's Name
First Name
Last Name
Subscriber's DOB
Insurance Company
*
Aetna
Allways Health Partners
Anthem NH
Beacon Health Strategies
Blue Cross Blue Shield
Boston Medical Center Health Net
CIGNA
Fallon
Harvard Pilgrim
Meritain Health
Neighborhood Health
OptumHealth Behavioral Solutions
PacifiCare
Qualcare
Tufts Health Plan
Tufts Direct
Tufts Navigator
Tufts Together
Tufts Unify
United Behavioral Health
Well Sense
Please take a picture of the FRONT of the card
*
Please take a picture of the BACK of the 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!
Submit Insurance Information
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