Insurance Information Form
For BCBS, Humana, Tricare and United/UMR providers only
Patient Information
Mother's Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Female
Male
N/A
Insurance Information
* BCBS of Texas doesn't pay for the baby. You will have to pay for your infant out of pocket. For everyone else, your infant will be covered.
Primary Insurance Company
*
Please Select
Aetna
Aetan/International/AFSPA
Aetan/Meritain
Aetna Better Health
Ambetter
Anthem Blue Cross
Anthem BCBS Connecticut
Anthem BCBS Georgia
Anthem BCBS Indiana
Anthem BCBS Kentucky
Anthem BCBS Maine
Anthem BCBS Missouri
Anthem BCBS New Hampshire
Anthem BCBS Ohio
Anthem BCBS Virginia
Anthem BCBS Wisconsin
Anthem Blue Cross California
Anthem Blue Cross Colorado
Anthem Blue Cross Nevada
BCBS Alabama
BCBS Ameriben
BCBS Arizona
BCBS Arizona Advantages
BCBS Arkansas
BCBS FEP
BCBS Illinois
BCBS Kansas
BCBS Louisiana
BCBS Massachusetts
BCBS Michigan
BCBS Minnesota
BCBS Nebraska
BCBS Nebraska
BCBS North Carolina
BCBS North Dakota
BCBS of Idaho
BCBS of Montana
BCBS of New Mexico
BCBS of Oregon
BCBS of Utah
BCBS Oklahoma
BCBS South Carolina
BCBS Tennessee
BCBS Texas
Capital BCBS Pennsyvania
CareFirst BCBS (MD/DC/VA)
Empire BCBS New York
Execellus BCBS New York
Florida Blue
Highmark BCBS Delaware
Highmark BCBS Pennsylvania
Highmark BCBS West Virgina
Horizon BCBS New Jersey
Independence Blue Cross (IBX)
Premera BCBS
Regence BCBS
Humana
Tricare
United
United/Savers
United/GEHA
United/Oxford
United/Surest
United/UMR
Other
If you do not see your insurance company's name, add it here.
Member ID No
*
Group No
*
Primary Insurance Phone No
*
Format: (000) 000-0000.
Subscriber's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Subscriber's Relationship to Patient
*
Name of Policy Holder
*
Date of Birth
*
-
Month
-
Day
Year
Date
Policy Holder's Address: Fill out if different from the mother's home address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Front of Insurance Card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back of Insurance Card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Baby's Information
* BCBS of Texas doesn't pay for the baby under lactation care. You will have to pay for your infant out of pocket. For everyone else, your infant will be covered.*
Baby's Name
*
First Name
Last Name
Baby's Date of Birth
*
-
Month
-
Day
Year
Date
Baby's Gender
*
Please Select
Female
Male
N/A
Is baby on a different insurance plan than the mother?
*
yes
no
Baby's Insurance
Use this section only if baby is on a different insurance plan than mother
Primary Insurance Company
Please Select
Aetna
Aetna/International/ AFSPA
Aetna/Mertain
Aetna Better Health
Ambetter
Anthem Blue Cross
Anthem BCBS Connecticut
Anthem BCBS Georgia
Anthem BCBS Indiana
Anthem BCBS Kentucky
Anthem BCBS Maine
Anthem BCBS Missouri
Anthem BCBS New Hampshire
Anthem BCBS Ohio
Anthem BCBS Virginia
Anthem BCBS Wisconsin
Anthem Blue Cross California
Anthem Blue Cross Colorado
Anthem Blue Cross Nevada
BCBS Alabama
BCBS Ameriben
BCBS Arizona
BCBS Arizona Advantages
BCBS Arkansas
BCBS FEP
BCBS Illinois
BCBS Kansas
BCBS Louisiana
BCBS Massachusetts
BCBS Michigan
BCBS Minnesota
BCBS Nebraska
BCBS Nebraska
BCBS North Carolina
BCBS North Dakota
BCBS of Idaho
BCBS of Montana
BCBS of New Mexico
BCBS of Oregon
BCBS of Utah
BCBS Oklahoma
BCBS South Carolina
BCBS Tennessee
BCBS Texas
Capital BCBS Pennsyvania
CareFirst BCBS (MD/DC/VA)
Empire BCBS New York
Execellus BCBS New York
Florida Blue
Highmark BCBS Delaware
Highmark BCBS Pennsylvania
Highmark BCBS West Virgina
Horizon BCBS New Jersey
Independence Blue Cross PA
Premera BCBS
Regence BCBS
Humana
Tricare
United
United/All Savers
United/GEHA
United/Oxford
United/Surest
United/Surest
United/UMR
Other
Primary Insurance if not in drop box
Member ID No
Group No
Primary Insurance Phone No
Format: (000) 000-0000.
Subscriber's Name (Baby's Insurance)
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Subscriber's Relationship to Patient
Subsciber's Address if different from Baby's home address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Front of Baby's Insurance Card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back of Baby's Insurance Card
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: