2026 Patient Update Form

FINANCIAL INFORMATION
Person financially responsible:
Name:

First NameLast Name
Relationship to Patient:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Number:
Format: (000) 000-0000.
Home Number:
Format: (000) 000-0000.
INSURANCE INFORMATION
Do you currently have medical insurance?
Is this an employer's health insurance plan or that of a family member?
Primary Insurance Company:
Policy Holder's Name:
Relationship to Patient:
Date of Birth:

MonthDayYear
SSN:
Policy Number/Member ID:
Group Number:
Patient's Name as listed on the insurance card:
Phone Number
Format: (000) 000-0000.
Do you have secondary insurance?
Secondary Insurance Company:
Policy Holder's Name:
Relationship to Patient:
Date of Birth:

MonthDayYear
SSN:
Policy Number/Member ID:
Group Number:
Patient's Name as listed on the insurance card:
Phone Number
Format: (000) 000-0000.
Do you have a separate prescription coverage?
Prescription Coverage Plan Name:
Member ID Number:
RxBIN:
RxPCN:
RxGRP:
Upload insurance card (both sides)

Cancelof
If you choose not to or are unable to upload your card/s here, please make sure to email copies to info@integrativebehavioralhp.com or text them to 984-288-0880.

Integrative Behavioral Health & Healing Practice