Identification & Insurance Cards
Beacon of Hope
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
How will you be paying for this appointment?
Insurance
Self-Pay
Photo ID - Front - (turn phone sideways)
Photo ID - Front
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Photo ID- Back - (turn phone sideways)
Photo ID- Back
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Insurance Card (primary) - Front - (turn phone sideways)
Insurance Card (primary) - Front
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Insurance Card (primary) - Back - (turn phone sideways)
Insurance Card (primary) - Back
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Do you have a secondary insurance plan in addition to your primary insurance?
Yes
No
Insurance Card (secondary) - Front - (turn phone sideways)
Insurance Card (secondary) - Front
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Insurance Card (secondary) - Back - (turn phone sideways)
Insurance Card (secondary) - Back
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Submit
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