Update your insurance information

Patient Name *

First

Last

Patient Date of Birth *//

Email *

Of the person filling out this form, in case we have any questions

New primary insurance *

Member ID# *

Insured's Name *

First

Last

Insured's Date of Birth *//

Patient's relationship to insured *

Insurance Card (front) *

Click or drag a file to this area to upload.

You may take and upload a picture or upload a pdf.

Insurance Card (back) *

Click or drag a file to this area to upload.

You may take and upload a picture or upload a pdf.

The above is the patient's... *

New Secondary insurance

New Secondary Member ID#

Secondary Insured's Name

First

Last

New Secondary Insured's Date of Birth//

Secondary Insurance Card (front)

Click or drag a file to this area to upload.

You may take and upload a picture or upload a pdf.

Secondary Insurance Card (back)

Click or drag a file to this area to upload.

You may take and upload a picture or upload a pdf.

Anything we should know about your insurance coverage?

e.g. What is the effective date of the new insurance? Is your address the same? If different, please list here, etc..

Authorization *

My signature below indicates that I am eligible to authorize the release of the personal health information of the patient listed above to the third party payer listed above in order for their claims to be processed, and for payment to be made directly to IPG for services rendered. I understand that the person responsible for the patient above is ultimately financially responsible to pay any balances owed after any third-party payments have been applied, or should any third-party payer decline to pay for some or all of the treatment at IPG.

Signature *

Therapist's Email

If you want your therapist to receive a notification that you've updated your insurance, select their email address above.