Update Your Insurance Information

The form below is only for use by existing clients who have already been seen at IPG.

Use this form to update the insurance card/plan we should send your claims to. Please also enter the new effective date of this information, whether it is primary or secondary, and anything else we should know about your insurance.

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Patient Name
Patient Date of Birth
Of the person filling out this form, in case we have any questions
Insured's Name
Insured's Date of Birth
Click or drag a file to this area to upload.
You may take and upload a picture or upload a pdf.
Click or drag a file to this area to upload.
You may take and upload a picture or upload a pdf.
e.g. What is the effective date of the new insurance? Is your address the same? If different, please list here, etc..
Authorization
Clear Signature
If you want your therapist to receive a notification that you've updated your insurance, type their email address above.