Insurance Consent
Patient's Full Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
Primary Insurance Name
*
Primary Card Holder Name
*
First Name
Last Name
Primary Card Holder Date of Birth
*
-
Month
-
Day
Year
Date
Relationship to Patient
*
Please Select
Self
Mother
Father
Guardian
Other
Insurance ID #
*
Group ID #
*
Card Holder's Employer
*
Secondary Insurance Name
Secondary Card Holder Name
First Name
Last Name
Secondary Card Holder Date of Birth
-
Month
-
Day
Year
Date
Relationship to Patient
Please Select
Self
Mother
Father
Guardian
Other
Insurance ID #
Group ID #
Card Holder's Employer
Please attach copies of Insurance Card and ID
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I authorize We Are Better Together, LLC to bill my insurance on my behalf.
Printed Name
*
First Name
Last Name
Today's Date
*
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Month
-
Day
Year
Date
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