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Section 1: Patient Information

You can upload a copy of your insurance cards below in Section 9.

Patient Account Number:
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Account numbers start with 3 characters. The dot is entered for you. No special characters are allowed.
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Section 2: Patient Demographic Information
Please use this section for changes and corrections to your demographic information to ensure that your insurance claims are processed in timely fashion.
(House number and street)
(If applicable)
Phone Number 1:
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Phone Number 2:
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Section 3: Insurer/Guarantor Information
Are you the parent, guardian or legally responsible person for the patient?

Section 4: Primary Insurance Information
Please fill in all information
Insurance Company Name:
(Address to submit claims to)
Phone Number:
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Fax Number:
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(if applicable)
Subscriber's Last Name: First Name: Middle Initial:
Subscriber's Date of Birth: (mm/dd/yyyy)
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Relationship to Patient: Explain, if Other:
Effective Dates of Insurance: (mm/dd/yyyy)
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To:
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Section 5: Motor Vehicle Accident / Worker's Compensation Claim
Please use this section to supply information if this is due to an auto accident or worker's compensation claim.
Insurance Company Name:
(This is the number given by your adjuster, not the policy number)
Date of Accident: (mm/dd/yyyy)
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Adjuster's Name:
Adjuster's Phone Number:
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Adjuster's Fax Number:
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Section 6: Secondary Insurance Information
Please fill in all information
Insurance Company Name:
Address to submit claims to
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Policy Number: (if applicable)
Subscriber's Last Name: First Name: Middle Initial:
Subscriber's Date of Birth: (mm/dd/yyyy)
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Relationship to Patient: Explain, if Other:
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Section 7: Tertiary Insurance Information
Please fill in all information
Insurance Company Name:
Address to submit claims to
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Policy Number: (if applicable)
Subscriber's Last Name: First Name: Middle Initial:
Subscriber's Date of Birth: (mm/dd/yyyy)
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Relationship to Patient: Explain, if Other:
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Section 8: Additional Comments
Please use this area to add any information that you feel would be important for us to make sure that your claim is handled in a expeditious manner.


Section 9: Upload Documents (optional)
Please use this area to add any JPG images of documents. Please upload a copy of your insurance cards, front & back.