Insurance Card and ID Card Submission Form (Behavioral Solutions P.C.)

Insurance Card and ID Card Submission Form
Please submit the information below regarding your insurance plan so we can ensure your insurance claims are being processed properly with accurate and current insurance information.
Date

MonthDayYear
Date
Client's Full Name*

First NameLast Name
Client's DOB*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this for a new client or an existing client updating their insurance?*

New ClientExisting Client
Therapist Name:*
What is the effective date of this new plan?
Insurance Company*
ID Number*
Who is the primary subscriber of this insurance (in relation to the client)?*

SelfSpouse or PartnerParent or Guardian
Subscriber's Name*

First NameLast Name
Subscriber's DOB*
Insurance Card

Please help us assure that all your insurance claims are processed properly. Send us a photo of the front and back of your insurance card. Please try to get the insurance card centered evenly in the screen.
Please take a picture of the FRONT of the card*
Please take a picture of the BACK of the card*
ID Card

Please send us a photo of the front side of your drivers license or state identification card. This is important for verifying your identity when billing your insurance. For minors, please submit the identification card of the parent or guardian.
Please take a picture of your State ID or Driver's License*
Please verify that you are human*
Should be Empty: