Insurance Billing Form

Insurance Billing Form

Please bring your insurance card(s) and photo ID to your appointment.
Patient Name*

First NameMiddle Name / MILast Name
Patient Date of Birth*

MonthDayYear
Date
Patient Address*

Street Address

Street Address Line 2

CityState

Zip
Patient Phone and Email*

Home PhoneCell PhoneEmail
Referring Physician*

NamePhone NumberFax Number
Primary Insurance Name*
Primary Policy Holder Name*
Primary Policy Holder Address*

Street Address

Street Address Line 2

CityState

Zip
Policy Holder Date of Birth*

MonthDayYear
Date
Policy Holder Social Security*
Primary Subscriber/ Member ID*
Include letters and numbers if applicable
Primary Group Nbr*
Secondary Insurance Name
Secondary Policy Holder Name
Secondary Policy Holder Date of Birth

MonthDayYear
Date
Secondary Policy Holder Social Security
Secondary Policy Holder Address

Street Address

Street Address Line 2

CityState

Zip
Secondary Subscriber/Member ID
Include letters and numbers if applicable
Secondary Group Nbr
FOR OFFICE USE ONLY - ACCESS CODE

End: Access Code Required
I agree that the doctor's billing department is authorized to submit insurance claims and follow up on insurance payments on behalf of my doctor.

For Billing or Insurance questions please contact Meghan at Argent Billing. Email: meghan@argent-billing.com
Signature*

Clear
Name*

First NameLast Name
Date

MonthDayYear
Date
Date*

MonthDayYear
Date
Should be Empty: