Insurance Billing Questionnaire
Please complete all areas below to help us best determine your coverage and estimated patient responsibility.
Full Legal Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Number
Please enter a valid phone number.
Format: (000) 000-0000.
Will you be using any insurance or will you be self-pay?
*
Insurance
Self-Pay
Call me to discuss
Insurance Company Name
Policy #
Please Upload the FRONT image of your insurance card:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please Upload the BACK image of your insurance card:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
If you have more than one insurance policy available, please email your additional images to: ccc.billing@trurcmservices.com.
What is your preferred method of contact for a member of our billing team to reach you?
*
Text
Email
Phone Call
By signing below, I acknowledge that the above information is accurate and I consent to contact based on my preferred methods of outreach as noted above.
*
Continue
Continue
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