Skip to content
Home
99-2-3NR2 PRIMARY New Patient Payment Details
New Patient Payment Details
Hidden
Visit_ID_Code
Hidden
Visit Details
– Fill Out Other Fields –
Hidden
Specialty forms
Hidden
Visit Reason ID Code
Hidden
Phone
Hidden
Email
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 Primary Insurance
(Required)
Blue Cross
Cigna
Aetna
United Healthcare/UMR
Medicare/Medicare Adv
Tricare
Humana
Other Insurances
We do not take ANY form of MEDICAID.
We can see Medicaid patients as self pay, but you can not file for reimbursement from Medicaid.
Many other insurances are out of network, and, beginning January 1, we will accept only limited number of out of network insurances. Visits with other out-of-network insurances will become self pay, and we can print receipt for you to file for reimbursement
Hidden
Other insurances we accept
Here are the other insurances we accept as in network or that pay out of network benefits
First Choice
Second Choice
Third Choice
Please type the insurance company name as it appears on your card
(Required)
Please type PO Box or mailing street address of the insurance as it appears on your card
(Required)
Insurance Group Name
Sometimes on your insurance card – PLEASE INCLUDE ANY NUMBER OR LETTER PREFIXES OR SUFFIXES
Insurance Group Number or ID
(Required)
On your insurance card – PLEASE INCLUDE ANY NUMBER OR LETTER PREFIXES OR SUFFIXES
Individual Subscriber/Member ID
(Required)
On your insurance card – PLEASE INCLUDE ANY NUMBER OR LETTER PREFIXES OR SUFFIXES
Patient relationship to the Policy Holder
(Required)
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)
Policy Holder Information
PRIMARY POLICY HOLDER / SUBSCRIBER Name
(Required)
First
Last
PRIMARY POLICYHOLDER Date of birth
(Required)
MM slash DD slash YYYY
PRIMARY POLICYHOLDER Mobile Phone
(Required)
PRIMARY POLICYHOLDER Email
(Required)
Policyholder social security number
(Required)
Hidden
Section Break
NOTE: We collect an ESTIMATE today of your balance due after filing with your insurance. Today’s collection is based on an initial inquiry of your benefits with your insurance company, but their quote of benefits is not always an accurate reflection of benefits or payment.
Once your claim is processed, You may owe additional funds or receive a refund once your claim is processed according to your plan.
Is the patient also covered by SECONDARY or SUPPLEMENTAL insurance?
(Required)
YES – Patient has SECONDARY insurance as well
NO – Patient has NO secondary insurance
