Insurance Submission

Do you believe your insurance company should have been billed?

If you believe that your insurance company should have paid all or a portion of an account placed with our office, and you would like us to submit your insurance information to our client for review, please complete the entire form below.

Consumer/Debtor Information
Name*
First Middle Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Email*
Phone
Claim Information
Patient Name*
First Last
Patient Date of Birth*
MM slash DD slash YYYY
Provider Name*
Doctor/Hospital
Date of Services*
MM slash DD slash YYYY
Insurance Company Information
Company Name*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone
Contact Person (if applicable)
Policy Information
Group Number*
ID Number
Policy Effective Date*
MM slash DD slash YYYY

When did this insurance policy start covering this patient
Enrollee/Member Name
Is this policy through your spouse or parent?
Other Information
Insurance Card*
Accepted file types: jpg, jpeg, png, pdf, docx, Max. file size: 10 MB.
Please attach a copy of the front and back of your insurance card.
Other
Phone
This field is for validation purposes and should be left unchanged.

Insurance Submission

Consumer/Debtor Information

Claim Information

Insurance Company Information

Policy Information

Other Information