Insurance Information

Insurance Information

For patients with out-of-network benefits who would like a superbill to submit on their own, or for Medicare patients. It takes about 2 minutes.
First Name
Last Name
Date of Birth (mm/dd/yyyy)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Patient's Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Upload a photo of your insurance card

The front of the card is enough. Lay it flat with all four corners showing.
Cancelof
Are you the primary card holder?
Card holder's first name
Card holder's last name
Card holder's date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Card holder's address
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Is your primary insurance Medicare?
How billing works

Original Medicare. We are a non-participating Medicare provider. We submit your claims directly to Medicare. You, or your secondary insurance, cover the 20% Medicare doesn't pay, along with any deductible.

Medicare Advantage and out-of-network benefits. We give you a superbill, an itemized receipt with the codes your insurer needs, and you submit it to your insurance for reimbursement.
Do you have secondary insurance?
Upload a photo of your secondary insurance card

The front of the card is enough. Lay it flat with all four corners showing.
Cancelof
Should be Empty: