Insurance Update Request Form
If you receive this form, we are needing your most updated insurance information for our records. Please complete and submit back to us as soon as possible. Thank you.
Client Name:
*
First Name
Last Name
Client DOB:
*
/
Month
/
Day
Year
Please enter the Client's DOB
Email (Optional)
example@example.com
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Insurance or Self-Pay Selection
Choose the option that applies.
Please select one of the following:
*
I DO have active insurance that I would like to update and submit.
I DO NOT currently have insurance and will be Self-Pay until further notice.
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PRIMARY INSURANCE
Please update our office with your current Insurance Information below.
PRIMARY - Insurance Company Name
*
Please type the name of your PRIMARY insurance company.
(P) - Member ID / Policy #
*
Please type your member ID as shown on your card.
(P) - Are you (the client) the Policy Holder of this Insurance?
*
Yes
No, I am not the Policy Holder
(P) Policy Holder's Name
*
First Name
Last Name
(P) Policy Holder's Relationship to Client
*
Example: Mother, Father, Spouse, Legal Guardian).
(P) Policy Holder's DOB
*
-
Month
-
Day
Year
Please enter the DOB of the Policy Holder if it is someone other than the client.
(P) Policy Holder's SSN # - (if applicable)
This information is used for insurance billing accuracy.
UPLOAD PRIMARY INSURANCE CARD HERE: To help us verify your insurance faster, please upload the requested documents
(P) FRONT of Primary Insurance:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
(P) BACK of Primary Insurance:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Save
SECONDARY INSURANCE
Do you have a Secondary Insurance?
*
Yes
No
SECONDARY - Insurance Company Name
*
Please type the name of your insurance company
(S) Member ID / Policy #
*
Please type your member ID as shown on your card.
(S) - Are you (the client) the Policy Holder of this Insurance?
*
Yes
No, I am not the Policy Holder
(S) Policy Holder's Name
*
First Name
Last Name
(S) Policy Holder's Relationship to Client
*
Example: Mother, Father, Spouse, Legal Guardian).
(S) Policy Holder's DOB:
-
Month
-
Day
Year
Please enter the DOB of the Policy Holder if it is someone other than the client.
(S) Policy Holder's SSN # - (if applicable)
This information is used for insurance billing accuracy.
UPLOAD SECONDARY INSURANCE CARD HERE: To help us verify your insurance faster, please upload the requested documents
(S) FRONT of Secondary Insurance:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
(S) BACK of Secondary Insurance:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Save
Thank You for Updating Your Information!
Final Page. (Please Submit your form once complete.)
REQUIRED:
*
By submitting, I confirm that the information provided is accurate and reflects my current insurance or self-pay status.
Today's Date
/
Month
/
Day
Year
Date
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