Update your insurance information

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, and whether it is primary or secondary.

(This form is only for use by those already receiving treatment).

Patient Name *

First

Last

Patient Date of Birth *//

Primary Insured's Name *

First

Last

Primary Insured's Date of Birth *//

Email *

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

Patient's relationship to primary insured

Insurance Provider (new) *

e.g. Aetna, Horizon BCBS, etc.

Member ID# *

This is the Patient's... *

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.

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 *

UPDATE YOUR INSURANCE INFORMATION

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