Client Insurance Information PhonePatient's Date of BirthPrimary Insurance CompanyPrimary Member's NamePrimary Member's Date o BirthPrimary Plan or Policy No.Primary Member ID or Certificate No.Primary Group No. (for Blue Cross only)Patent Relation to Member (Primary Plan) Insured MemberSpauseChildHandicapped DependentPart Time StudentFull Time StudentDomestic PartnerSecondary Insurance CompanySecondary Plan or Policy No.Secondary Member ID or Certificate No.Patent Relation to Member (Secndary Plan)Insured MemberSpauseChildHandicapped DependentPart Time StudentFull Time StudentDomestic PartnerWhat are your main complaints?/ Problem locations/When did it start?/ How?Describe the pain (if any)Dull/AchesShootingPin PrickTightSqueezingBand SensationExpandingPlease note, if insurance response is PENDING, we will follow instructions set out by your insurance company to void the claim and resubmit to be payable to the insured member. Hence, in such cases, we will collect the full visit amount up front and your insurer will pay you, the insured member, after. Please also note that we are unable to direct bill to your secondary insurance company. We ask that you pay your remaining balance up and submit your receipt to your secondary insurance company after. I accept terms & conditionsSendThis field should be left blank
