Cape Medical Billing: Providing Expert Medical Billing Solutions

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Section 1: Patient Information

Patient Account Number:
.

Account numbers start with 2 letters. The dot is entered for you. No special characters are allowed.

Patient Name: Last First Middle Initial Suffix:

Patient's Social Security Number:

*Patient's Date of Birth:

(mm/dd/yyyy)

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.

Patient Address: (House number and street)

Apartment Number: (if applicable) City: State: Postal Code:

Phone Number 1:

Phone Number 2:

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: (Address to submit claims to)

City: State: Postal Code:

Phone Number:

Fax Number:

Policy Number: Group Number: (if applicable)

Subscriber's Last Name: First Name: Middle Initial:

Subscriber's Date of Birth:

(mm/dd/yyyy)

Relationship to Patient: Explain, if Other:

Effective Dates of Insurance:

(mm/dd/yyyy)

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.

Type of Claim: Is your Claim

Insurance Company Name:

Address: City: State: Postal Code:

Claim Number: (This is the number given by your adjuster, not the policy number)

Date of Accident:

(mm/dd/yyyy)

Adjuster's Name:

Adjuster's Phone Number:

Adjuster's Fax Number:

Section 6: Secondary Insurance Information
Please fill in all information

Insurance Company Name:

Address: (Address to submit claims to)

City: State: Postal Code:

Phone Number:

Fax Number:

Policy Number: Group Number: (if applicable)

Subscriber's Last Name: First Name: Middle Initial:

Subscriber's Date of Birth:

(mm/dd/yyyy)

Relationship to Patient: Explain, if Other:

Effective Dates of Insurance:

(mm/dd/yyyy)

Section 7: Tertiary Insurance Information
Please fill in all information

Insurance Company Name:

Address: (Address to submit claims to)

City: State: Postal Code:

Phone Number:

Fax Number:

Policy Number: Group Number: (if applicable)

Subscriber's Last Name: First Name: Middle Initial:

Subscriber's Date of Birth:

(mm/dd/yyyy)

Relationship to Patient: Explain, if Other:

Effective Dates of Insurance:

(mm/dd/yyyy)

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.