INSURANCE BILLING QUESTIONNAIRE

INSURANCE BILLING QUESTIONNAIRE

PLEASE COMPLETE ALL AREAS BELOW TO HELP US BEST DETERMINE YOUR COVERAGE AND ESTIMATED PATIENT RESPONSIBILITY
FULL LEGAL NAME*

First NameLast Name
DOB*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CELL NUMBER*
Please enter a valid phone number.
HOME NUMBER
Please enter a valid phone number.
WILL YOU BE USING ANY INSURANCE, OR WILL YOU BE SELF-PAY?

INSURANCESELF-PAYCALL ME TO DISCUSS
INSURANCE COMPANY NAME
POLICY #
PLEASE UPLOAD THE FRONT IMAGE OF YOUR INSURANCE CARD

Cancelof
PLEASE UPLOAD THE BACK IMAGE OF YOUR INSURANCE CARD

Cancelof
IF YOU HAVE MORE THAN ONE INSURANCE POLICY AVAILABLE, PLEASE EMAIL ADITIONAL IMAGES TO: INFO@CAROLINASCC.COM
WHAT IS YOUR PREFERRED METHOD OF CONTACT FOR A MEMBER OF OUR BILLING TEAM TO REACH YOU?*

TEXTEMAILPHONE CALL
BY SIGNING BELOW, I ACKNOWLEDGE THE ABOVE INFORMATION IS ACCURATE AND I CONSENT TO CONTACT BASED ON MY PREFERRED METHODS OF OUTREACH AS NOTED ABOVE
Signature*

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