Health Plan and Insurance Coverage Form
Patient's Name:
First Name
Last Name
Patient's Date of Birth
-
Month
-
Day
Year
Date
Please choose the insurance company for your primary health insurance:
*
Horizon
Aetna
Amerihealth
Amerihealth Administrators
United
Cigna
Independence Blue Cross
Keystone Health Plan East
Tricare
Other
If you replied "Other," please specify:
Please list the Policy Number or Member ID found on your insurance card:
*
Who is the subscriber for the primary insurance?
*
First Name
Last Name
What is the subscriber's date of birth?
*
-
Month
-
Day
Year
Date
Please upload a picture or scan of the patient's Primary Insurance Card: (FRONT and BACK)
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Does the patient have any secondary insurance coverage?
*
Yes
No
Please state the insurance company for your secondary health insurance(if applicable):
Please list the Policy Number or Member ID for your secondary insurance:
Who is the subscriber for the secondary insurance?
First Name
Last Name
What is the secondary insurance subscriber's date of birth?
-
Month
-
Day
Year
Date
Please upload any Secondary Insurance Cards if applicable: (FRONT and BACK)
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Cancel
of
Is the Patient's Health Insurance: Plan/ Insurer/ Design changing as of 1/1/2018?
*
Yes, I have the information related to the plan effective 1/1/2018
Yes, but I do NOT have the information related to the plan effective 1/1/2018
No all insurance information will remain unchanged, including Plan, Identification Number, and group number
I am not sure, but I will find out soon and email the office
Is your plan a calendar year or contract year
*
Calendar Year
Contract Year
Unsure
If 'yes' please state when your policy starts and ends
Please list the Health Insurance Plan Sponsor/ Employer: (this is typically an employer, union or a government agency)
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