Insurance Billing Form

Insurance Billing Form

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

First Name Middle Name / MI Last Name
Patient Date of Birth *

Month Day Year
Date
Patient Address *

Street Address

Street Address Line 2

City State

Zip
Patient Phone and Email *

Home Phone Cell Phone Email
Referring Physician *

Name Phone Number Fax Number
Primary Insurance Name *
Primary Policy Holder Name *
Primary Policy Holder Address *

Street Address

Street Address Line 2

City State

Zip
Policy Holder Date of Birth *

Month Day Year
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

Month Day Year
Date
Secondary Policy Holder Social Security
Secondary Policy Holder Address

Street Address

Street Address Line 2

City State

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 call Terri at Echo Billing Solutions 847-847-1792 ext. 68 or email Terri@echobillingsolutions.com
Signature *

Clear
Name *

First Name Last Name
Date *

Month Day Year
Date
Should be Empty: