JORDAN WEST FAMILY COUNSELING INSURANCE CHANGE REQUEST FORM

JORDAN WEST FAMILY COUNSELING

INSURANCE CHANGE REQUEST FORM
PATIENT INFORMATION
Client Name
DOB

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone
UPDATED PRIMARY PAYMENT SOURCE
Payment Source (Insurance, EAP, other)
Please provide the name of the EAP or Insurance company
Phone Number (Insurance, EAP, other)
Payment Source Address City, State, Zip
Authorization Number, If yes please provide AUTHORIZATION NUMBER

EAP? Yes No
AUTHORIZATION NUMBER
Insured Name
Insured Date of Birth (for authorization purposes)

Month Day Year
Date
Insured Address: City, State, Zip
PLEASE UPLOAD A COPY OF NEW INSURANCE CARD (FRONT AND BACK)

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Cancel of
Include a copy of the FRONT and BACK sides of the Insurance Card.
I, the undersigned, certify that I (or my dependent) have insurance coverage with
Name of insurance company, EAP , or other
and assign directly to my provider all insurance benefits otherwise payable to me for services rendered. I understand that I am ultimately responsible for all charges accumulated. I hereby authorize Jordan West Family Counseling to release all information necessary to secure the payment of benefits, and authorize the use of this signature on all insurance submissions.
Patient Name *
Relationship to Patient *
Authorized Person *
Signature *

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Date

Month Day Year
Date Hour Minutes AM/PM Option
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