Change of Insurance Form

Change of Insurance Form
Today's Date *

Month Day Year
Date
Patient's Name *

First Name Last 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? *

Yes No
If you are adding this insurance as a second insurance, please check the appropriate box below:

The old insurance is my primary insurance The 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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Cancel of
Please upload a picture of the BACK of your new insurance card.

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Cancel of
The Boston Ability Center is in-network with Blue Cross Blue Shield and AllWays. The Boston Ability Center is out-of-network with United Healthcare, Harvard Pilgrim PPO, and Aetna. All other insurance plans are self pay at our facility (Harbard Pilgrim HMO, Cigna, Tufts, Mass Health Plans, etc.). 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 Center My new insurance carrier is out-of-network at the Boston Ability Center My 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 Name Last Name
Date *

Month Day Year
Date
Should be Empty: