"*" indicates required fields HiddenVisit ID Z Code HiddenSource HiddenVisit Details– Fill Out Other Fields –HiddenPatient ID HiddenFront Desk Submitting HiddenPatient Primary Insurance CarrierFirst ChoiceSecond ChoiceThird ChoiceSource of insurance detailsPV EligibilityAvailityUHC PortalMedicare PortalPatient insurance cardOtherCopay*Outstanding Deductible*Co-insurance Percent*Please enter a number from 0 to 100.Visit Total from PV*HiddenAmount to collect