Billing Inquiry Form

Billing Inquiry

This form is for current clients only! Please complete this form to request customer service support from our billing team. Please provide as much detail as possible and we will get back to you within 2 business days. Thank you!
Today's Date

MonthDayYear
Date
Client's Full Name*

First NameLast Name
Client's Date of Birth*

MonthDayYear
Date
Request Type*

I have new insurance to reportI have a question about my benefitsI have a question on my bill or balanceI have a question about a claimI would like to pay my billI would like to discuss payment optionsI would like to request a refund
Please provide more details regarding your request:
How would you like us to contact you?*

Phone CallEmail
Phone Number
Please enter a valid phone number.
Email
example@example.com
Primary Insurance

Please Note: We are NOT currently participating providers with MassHealth
Insurance Company*
Insurance ID (include any letters and numbers)*
Who is the primary subscriber of this insurance?*

SelfSpouse or partnerParent / Legal GuardianGrandparent or Family MemberOther
Primary Subscriber's Name

First NameLast Name
Subscriber's DOB
Insurance Card:

We know this is a little tricky...Position the card so that it is close enough to fill most of the screen and straight as possible. Make sure the lighting is good, and watch your fingers!
Please take a picture of the FRONT of the card
Please take a picture of the BACK of the card
Integrated Behavioral Care makes every effort to provide the most up to date information the insurance company has regarding member eligibility and benefits. However, we cannot guarantee that the information has not changed, was given incorrectly, or will not change since being obtained. The information obtained from the member's insurance company is not a guarantee of payment. Benefits are subject to eligibility at the time of service and all plan conditions, limitations and exclusions. We encourage all clients to verify their eligibility and benefits information with their insurance company as well.
Should be Empty:

Billing Inquiry

Primary Insurance