Branch Mental Health PLLC
651-333-3677 (phone) | www.branchmentalhealth.com
Insurance Information
Please complete the following form if you would like us to bill your insurance.
PATIENT'S Name
*
First Name
Middle Name
Last Name
PATIENT'S date of birth
*
-
Month
-
Day
Year
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Is this claim related to work comp or an employment injury?
*
Yes
No
Is this claim related to an auto (or other) accident?
*
Yes
No
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PRIMARY INSURANCE
Please complete the information below for patient's PRIMARY insurance. There is a section on the next page to complete any information for SECONDARY insurance, if needed.
Name of individual who carries the policy?
*
First Name
Middle Name
Last Name
Address of policyholder (only complete if the address is different from the address we have on file for patient):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone number of policyholder (if different from patient)
Please enter a valid phone number.
Format: (000) 000-0000.
Policyholder date of birth (if different from patient)
-
Month
-
Day
Year
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Policyholder's employer (if this is a state plan, please write "n/a" in the blank below):
*
Relationship to patient:
*
Please Select
self
mother
father
other (please describe below)
If "other" relationship, please describe:
Please upload insurance card below.
File Upload - Please upload a readable photo or copy of the FRONT of patient's insurance card.
*
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Choose a file
Cancel
of
File Upload - Please upload a readable photo or copy of the BACK of patient's insurance card.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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SECONDARY INSURANCE
Please complete this section only if patient has a 2ND insurance you would like us to submit claims to. Otherwise, please select the blue "NEXT" button at the bottom of the page to skip this section.
Name of individual who carries the policy?
First Name
Middle Name
Last Name
Address of policyholder (only complete if the address is different from the address we have on file for patient):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone number of policyholder (if different from patient)
Please enter a valid phone number.
Format: (000) 000-0000.
Policyholder date of birth (if different from patient)
-
Month
-
Day
Year
Date Picker Icon
Policyholder's employer (if this is a state plan, please write "n/a" in the blank below):
Relationship to patient:
Please Select
self
mother
father
other (please describe below)
If "other" relationship, please describe:
Please upload insurance card below.
Please upload a readable photo or copy of the FRONT of SECONDARY insurance card, if applicable. Otherwise leave this section empty.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload a readable photo or copy of the BACK of SECONDARY insurance card, if applicable. Otherwise leave this section empty.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
AUTHORIZATION
Please review the terms and conditions, sign, and submit your form. Thank you!
Anything else you would like us to know regarding insurance?
TERMS AND CONDITIONS
By signing this form, I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits (where applicable) either to myself or to the party who accepts assignment. I authorize payment of medical benefits to Branch Mental Health PLLC or the provider (Sarah Myer, APRN, CNP), for healthcare services provided. Signature of patient (or legal guardian):
PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE:
*
E-mail address:
example@example.com
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