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Secondary Insurance – New Patient
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Visit_ID_Code
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Visit Details
– Fill Out Other Fields –
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Specialty Forms
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Visit Reason ID Code
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Method of Payment
(Required)
Self Pay – Urgent Care
Insurance – Urgent Care
Workers Comp/Work Injury
Employer Paid Services (drug screens, DOT, etc)
Who is the Network Insurance Provider for your SECONDARY Insurance
(Required)
Blue Cross
Cigna
Aetna
United Healthcare/UMR
Medicare Supplement/Medicare Adv
Tricare
Humana
Other Insurances
Please type the SECONDARY insurance company name as it appears on your card
(Required)
Please type SECONDARY insurance PO Box or mailing street address as it appears on your card
(Required)
SECONDARY Insurance Group Name
Sometimes on your insurance card – PLEASE INCLUDE ANY NUMBER OR LETTER PREFIXES OR SUFFIXES
SECONDARY Insurance Group Number or ID
(Required)
On your insurance card – PLEASE INCLUDE ANY NUMBER OR LETTER PREFIXES OR SUFFIXES
SECONDARY Individual Subscriber/Member ID
(Required)
On your insurance card – PLEASE INCLUDE ANY NUMBER OR LETTER PREFIXES OR SUFFIXES
Patient relationship to the SECONDARY Policy Holder
(Required)
Same as PRIMARY insurance policy holder
Patient is the Policy Holder
Parent/Guardian filling out this paperwork is the Policy Holder
A DIFFERENT Parent/Guardian who is NOT filling out this paperwork is the Policy Holder
Spouse of Patient is the Policy Holder
Other
Describe Other Policy Holder Relationship
(Required)
SECONDARY Policy Holder Information
SECONDARY POLICY HOLDER / SUBSCRIBER Name
(Required)
First
Last
SECONDARY POLICYHOLDER Date of birth
(Required)
MM slash DD slash YYYY
SECONDARY POLICYHOLDER Mobile Phone
(Required)
SECONDARY POLICYHOLDER Email
(Required)
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Policyholder social security number
(Required)
