Insurance Information Updates for 2026
This form is for CURRENT KCC clients to inform us of any CHANGES to their insurance policies for 2026. If you have any changes to report, they should be made using this form, not the client portal. Thank you for your partnership!
Insurance
WE ONLY BILL PRIMARY INSURANCE POLICIES. WE ARE IN-NETWORK WITH BCBS (NOT BLUE VALUE, BLUE LOCAL, OR BLUE HIGH PERFORMANCE NETWORK), AETNA, UNITED, CIGNA, AND MEDICAID (HEALTHY BLUE (INCLUDING CARE TOGETHER), PARTNERS, AND TRILLIUM ONLY).
Client Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Insurance Information
Do you want us to bill insurance for services in 2026?
*
YES
NO
Select one
*
I am using my PRIMARY AETNA plan
I am using my PRIMARY CIGNA plan
I am using my PRIMARY UNITED HEALTHCARE plan
I am using my PRIMARY BCBS plan (NOT Blue Value or Blue Local)
I am using my PRIMARY MEDICAID plan - Healthy Blue OR Healthy Blue Care Together
I am using my PRIMARY MEDICAID plan - Partners
I am using my PRIMARY MEDICAID plan - Trillium
If we are out-of-network with your insurance carrier, we will provide a superbill (medical receipt) that you can submit to your insurance company for possible reimbursement for out-of-network benefits. Select one of the options below.
I am NOT using insurance and DO NOT want a superbill
I am NOT using insurance and DO want a superbill
Primary Insurance Co
*
Policy No
*
Group No
*
Primary Insurance Phone No
Policy Holder's Name
*
First Name
Last Name
Policy Holder's Date of Birth
*
-
Month
-
Day
Year
Date
Policy Holder's Relationship to Client
*
Upload Insurance Card - Front and Back
*
Browse Files
Drag and drop files here
Choose a file
Upload a picture of the front and back of your insurance card here.
Cancel
of
336-283-3830
Submit
Should be Empty: