Insurance Form
Please enter information in the space below
What is your relationship to the patient?
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I am the patient
Parent / Legal guardian
Other
What is your name?
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First Name
Last Name
What is the patient's name?
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First Name
Last Name
Insurance Company
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Blue Cross Blue Shield, Aetna, etc.
Member ID#
*
Please re-enter Member ID#
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Please upload a visible picture of the FRONT of your insurance card
*
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Please upload a visible picture of the FRONT of your insurance card
*
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Do you have multiple insurances like a commercial insurance and Medicaid or Medicare and a Medicare supplemental plan?
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Yes
No
Insurance Company
*
Blue Cross Blue Shield, Aetna, etc.
What is the member ID# of your second insurance plan
*
Please re-type the member ID# of your second insurance plan
*
Please upload a visible picture of the FRONT of your second insurance card
*
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Please upload a visible picture of the BACK of your second insurance card
*
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of
By signing this form below, I understand and agree to the following: I authorize the release of information from my medical record to the insurance companies or other third-party payers named below. This information shall include all information necessary to submit and process claims, such as my name, date of birth, address, medical diagnosis, and services provided to me. If the practice has already shared information with the insurance company or other third-party payer at the time I revoke this authorization, it is too late to prevent that information from being shared. This authorization is necessary for the practice to determine eligibility for treatments or benefits or to pay for treatments I receive, but the practice cannot condition treatment on the provision of this authorization. This authorization shall be effective for 1 year from the date of my signature, unless I contact the practice in writing any time prior to then to revoke. If you are using Medicare benefits, you also agree to the following: I request that payment of authorized Medicare benefits be made either to me or on my behalf to the name of provider of service and (or) supplier for any services furnished to me by that provider of service and (or) supplier. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related service. In consideration of the services provided to me, I assign all benefits to the practice, if accepted, and authorize this insurance company to make payments directly to the practice and its affiliates on my behalf.
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