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99 FD-ADMIN Manage Insurance List
Search for insurance
Edit existing insurance
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Date of edit
MM slash DD slash YYYY
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Edited by
Select insurance to edit
Search partial name insurance name to edit
Select Insurance Company
– Fill Out Other Fields –
Selected Insurance Name
read only – Edit below
Selected address
read only – Edit below
Insurance Record
Add as new
add as new insurance company
Insurance Company Name (all caps)
(Required)
Insurance Active
(Required)
Yes, Active insurance
No, deactivate insurance so can not be selected
Insurance Address (Include words PO BOX or Street address in all caps)
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Insurance Financial Class
(Required)
Self Pay – Personal
Blue Cross (2)
Medicare (3)
DOT Exam (4)
Medicare Advantage (5)
EPS (9)
Other government (11)
Humana (12)
Tricare (13)
Coventry (14)
United Healthcare/UMR (15)
Other Commercial (16)
Aetna (17)
Cigna (18)
Workers Comp (20)
Baylor S&W (25)
Imagine360 (26)
Insurance Category
(Required)
Private contracted insurance
Out of network private
Self Pay – individual
Public contracted insurance
Out of network public
Contracted WC
Out of network WC
Self Pay – Company
Unknown
Insurance Tevix ID
Insurance processing instructions
