Clone of 13) Send Us a msg or doc

Send us Your New Insurance Information
Who is your clinician?
We will send the information to our business office and your clinician for updating.

Please Complete the following for your new insurance:

Rows	Answers:
Insurance Plan:
Policy ID #:
Group ID #:
Subscriber Name:
Subscriber DOB:
Subscriber Address (enter "same" if at the same address as client):
Subscriber Relationship to Client
Is this a change from the plan from 2025, a new plan, or?
Is there a plan(s) we need to stop using from 2025?

Are there any other health plans for this client?
Do we have the other insurance information already?
When you are finished with this form, please complete another one for each additional health plan. Thanks!
Please upload a copy of the FRONT of your health plan card.

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Please upload a copy of the BACK of your health plan card.

Browse Files

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Your name:
Your email or phone:
So we can contact you if needed.
Any additional information that would be important about your insurance plan(s):
When you are finished, press SUBMIT.
STAFF: Use the password to open the attachment.

Then, you will see either a picture in the attachment, or a link to a document.

If it is a document (i.e., a PDF file), then click on it. It will automatically download, and should appear at the bottom of the browser window. If it doesn't, check your downloads folder. It should appear there.
Should be Empty:

Send us Your New Insurance Information