Change of Insurance Form

Change of Insurance Form
Today's Date*

MonthDayYear
Date
Patient's Name*

First NameLast Name
Old Insurance Company*
Old Insurance Policy Number*
End Date for Old Insurance*
New Insurance Carrier*
New Insurance Policy Number*
New Insurance Start/Effective Date*
Subscriber's Name*
Subscriber's Date of Birth*
Are you adding this insurance as a secondary insurance?*

YesNo
If you are adding this insurance as a second insurance, please check the appropriate box below:

The old insurance is my primary insuranceThe new insurance is my primary insurance
Please list the policy number of your new PRIMARY insurance. *
Please upload a picture of the FRONT of your new insurance card.

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Cancelof
Please upload a picture of the BACK of your new insurance card.

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Cancelof
The Boston Ability Center is in-network with Blue Cross Blue Shield and AllWays. All other insurance plans are considered self-pay at our facility. Based on this information, please select which of the following statements applies to your NEW insurance carrier.*

My new insurance carrier is in-network at the Boston Ability CenterMy child's services at the Boston Ability Center will be self-pay
By signing this form, you are acknowledging...
- It is the family's responsibility to verify insurance coverage, including but not limited to: prior authorization and referral requirments and obtaining said authorization or referral when necessary; deductible and copayment amounts; and any coverage limitations.
- Providing the insurance information does not guarantee coverage of services provided.
- If this information was provided after the effective date of the new plan, Boston Ability Center is not responsible for any charges not covered by the insurance company for any reason.
- All inforamtion provided on this form is accurate.
Parent/Legal Guardian's Signature*

Clear
Printed Name of Parent/Legal Guardian*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty: