Insurance Information
Patient's name
*
Date of birth
*
-
Month
-
Day
Year
Phone Number
Please enter a valid phone number.
Email
example@example.com
Please note that while Carolina Center does not accept Blue Cross/Shield, Medicare or Medicaid and can only file certain claims with other insurance carriers, we are able to utilize most major insurance for certain labs and prescriptions. PLEASE PROVIDE A COPY OF YOUR INSURANCE CARD SO WE CAN HELP YOU FILE CLAIMS IF ABLE. 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.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back of primary 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
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
Emergency Contact Information
Name
First Name
Last Name
Relationship to Patient
Please Select
Spouse
Parent
Child
Sibling
Friend
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pharmacy Information
Name of Pharmacy
Pharmacy Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pharmacy Phone Number
Please enter a valid phone number.
HIPPA Privacy Authorization Form
Do you wish to authorize Carolina Center for Integrative Medicine to release any and all medical information and test results that pertain to you, to someone else?
Authorized Person
First Name
Last Name
Email
example@example.com
Relationship to Patient
Please Select
Spouse
Parent
Child
Sibling
Friend
Phone Number
Please enter a valid phone number.
Date
-
Month
-
Day
Year
Date
Signature
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