Health Insurance Form
Patient Information
Name
*
First Name
Last Name
Last Name of clinician patient is seeing at PsychCare
Aloni
Andrews
Bathurst
Betz
Breuer
Christiansen
Clare
Dauler
DeBroeck
Diez
Garratt
Griffin
Grossman
Izant
Janowski
Karecha
Katz
Koenig
Krause
Krum
Land
Lee
Leone
Lipkin
Mays
McGuire
Millman
Musman
Murphy
Neelapareddy
Nickie
Peske
Pollard
Robinson
Rutledge
Siegelman
Smithmyer
Williams
Zimmerman
Insurance
Information
Primary Insurance Co
*
Policy No
*
Group No
*
Primary Insurance Phone Number for Providers (Usually Listed on Back of Card)
*
-
Area Code
Phone Number
Subscriber's Relationship to Patient
*
Self
Spouse
Child
Subscriber's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Do you have a Secondary Insurance
*
No
Yes
Secondary Insurance Co
*
Policy No
*
Group No
*
Secondary Insurance Phone No
*
-
Area Code
Phone Number
Subscriber's Relationship to Patient
*
Self
Spouse
Child
Subscriber's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: