Change of Insurance Form

Today's Date*

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

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The Boston Ability Center is in-network with Blue Cross Blue Shield, Tricare and most Mass General Brigham Health Plans (formally known as Allways Health Plans). We are NOT in-network with MGBHP ACO plans. All other insurance plans are out-of-network and considered self-pay at our facility. This includes United Healthcare, Harvard Pilgrim, Cigna, Aetna, Tufts, Fallon, MassHealth 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 CenterMy child's services at the Boston Ability Center will be self-pay

BAC does not have contact with your insurance and will not submit claims, request prior authorizations, request visit extensions, file appeals, or submit medical records or any additional requirements that may be needed by your insurance. We cannot accept in-network provider exception agreements, in-network payment agreements, or single case agreements with your insurance company.

If you would like to submit for reimbursement directly from your insurance carrier, we will provide you with monthly statements and detailed receipts and upon request, will provide a progress note every 8 weeks. If you choose to work directly with your insurance company, we suggest you contact them prior to services regarding coverage, authorization requirements, deductible and copay/co-insurance amounts, and any limitations your plan may have.

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*

Printed Name of Parent/Legal Guardian*

First NameLast Name

Date*

Date