Insurance Forms
Patient Insurance Information Submission Form
Please print, complete and fax (360-425-7219) or mail PO Box 3012, Longview, WA 98632) the following information
| Account # | ________________________ | ||
| Patient Information | Insurance Company Information | ||
| Patient Name__________________________________ | Company Name_______________________________________ | ||
| Street Address_________________________________ | Company Mailing Address______________________________________ | ||
| City_______________________________________ | City__________________________________ | ||
| State__________________ | State____________________ | ||
| Zip_________________ | Zip____________________ | ||
| Home Phone________________________________ | Company Phone_______________________ | ||
| E-mail______________________________________ | |||
| Social Security Number_______________________ | |||
| Patient Birth date_____________________________ | |||
Policy Holder Information |
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| Policy Holder Name____________________________ | Policy Holder SSN__________________________ | ||
| Relationship to Patient__________________________ | Employer__________________________________ | ||
| Insurance Policy Number________________________ | Insurance Group Number_____________________ | ||
| Secondary Insurance Information______________________________________________________________________ _______________________________________________________________________________ |
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| Notes/Comments_____________________________________________________ ____________________________________________________________________ |
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