Insurance Card

Insurance Card
Patient Information
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Upload Front & Back of Insurance Card *

Cancel of
Please verify that you are human *
Note: If submit button is not working, required information is not filled out.

Please scroll up to double check your information.
8550 Cuthills Circle Lincoln, NE 68526 | alivation.com | info@alivation.com

Behavioral Health | Phone: 402.476.6060 | Fax: 402.476.6809

Primary Care | Phone: 402.466.3355 | Fax: 402.466.3410
Should be Empty:

Patient Information