Insurance Update
Patient ID (if known)
Patient Full Name
*
First Name
Middle Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Birthdate
Email of person completing this form
*
example@example.com
Please Select Your Insurance Carrier
*
Please Select
Aetna
Anthem Blue Cross
Beacon
Blue Shield
Blue Shield UCBSHIP - UC Berkeley
Cigna
Cigna Behavioral
ComPsych
EBAC
Humana
Kaiser
Lincoln Center
Magellan
Medi-Cal
MHN
Tricare
United Healthcare (Optum)
Valley Health Plan
Value Options
Other/ Not Listed
No Insurance
Private Pay
Enter your insurance member ID
*
Enter your insurance group number
*
Enter 'NONE' if no group number
Please upload an image of the FRONT of the primary insurance card.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload an image of the BACK of the primary insurance card.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Who is the insurance policyholder?
*
Parent or Guardian
Patient
Other - Enter Relationship Here
Insurance Policyholder
*
First Name
Last Name
Policyholder Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Birthdate
Policyholder Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is there more than one insurance policy?
*
No
Yes
Not Sure
Save
Submit
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