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Patient Insurance Primary Policyholder Secondary Policyholder Responsible Party

Patient Information -

Please write information about the patient here

Insurance Information -

Please write information about the patient’s insurance here

Primary Insurance Company Name:
Insurance Company
Address:
City:
State:
Zipcode:
Insured's ID Number:
Group Plan Number:
Secondary Insurance Company Name:
Secondary Insurance Company
Address:
City:
State:
Zipcode:
Insured's ID Number:
Group Plan Number:
Employer Plan Coverage?:
CHAMPUS:
Branch of Service:

Primary Policyholder Information -

Complete the information below if the PATIENT is NOT the POLICYHOLDER

Responsible Party Information

Please complete the information below if the person responsible for paying the bill is NOT the PATIENT or the POLICYHOLDER

Signature:
Date Signed:
BY TYPING MY SIGNATURE I CERTIFY THAT THE INFORMATION PROVIDED ON THIS FORM IS TRUE AND CORRECT. I CONSENT TO TREATMENT AND AGREE TO THE ASSIGNMENTS AND FINANCIAL RESPONSIBILITIES SHOWN BELOW THIS FORM. YOU SHOULD READ THESE TERMS CAREFULLY.