Insurance Information
Patient's name
*
Date of birth
*
-
Month
-
Day
Year
Please note that Carolina Center does not accept Blue Cross/Shield, Medicare or Medicaid. Excluding those carriers, do you have health insurance?
*
Yes, I have a primary insurance
Yes, I have primary and secondary insurances
No, I do not have health insurance
Are you the policyholder on this primary insurance?
*
Yes
No
Front of primary insurance card.
*
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Cancel
of
Back of primary insurance card.
*
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Choose a file
Cancel
of
Subscriber's name
*
Birthdate of subscriber
*
-
Month
-
Day
Year
Sex of subscriber
*
Please Select
Male
Female
Relationship to patient
*
Please Select
Parent
Spouse
Domestic Partner
Other
Are you the policyholder on this secondary insurance?
*
Yes
No
Front of secondary insurance card.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back of secondary insurance card.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Subscriber's name
*
Birthdate of subscriber
*
-
Month
-
Day
Year
Sex of subscriber
*
Please Select
Male
Female
Relationship to patient
*
Please Select
Parent
Spouse
Domestic Partner
Other
Submit
Should be Empty: