• JORDAN WEST FAMILY COUNSELING

    INSURANCE CHANGE REQUEST FORM

  • PATIENT INFORMATION

     

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  • UPDATED PRIMARY PAYMENT SOURCE

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  • Include a copy of the FRONT and BACK sides of the Insurance Card.

  • 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.

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