Seattle Insurance Verification Request Form

1
Patient Name* This field is required.Full name as it appears on the policy
First Name
Middle Name
Last Name
2
Patient Date of Birth* This field is required.Patient
Date
Year
Month
Day
3
Email* This field is required.
example@example.com
Confirm Email
4
Phone Number* This field is required.
5
Insurance Provider Name* This field is required.Please specify the Insurance Company name from the list below
Aetna
Blue Cross Blue Shield
Cigna
GHI
Oxford
United Healthcare
UMR
Medicare
Other
6
Member Identification Number* This field is required.Please Include the 3 letter Prefix if there is one
This is not the Insurance Policy Number
7
Group Number* This field is required.Please Include if available
8
Is this patient the Primary Member?* This field is required.
YESNO
9
Name of Primary Policy Member* This field is required.Full Name of Policy Holder as it appears on the Policy
First Name
Last Name
10
Date of Birth of Primary Member* This field is required.
Date
Year
Month
Day
11
Do you have a secondary insurance policy?
YESNO
12
Secondary Insurance Provider Name* This field is required.Please specify the Insurance Company name from the list below
Aetna
Blue Cross Blue Shield
Cigna
GHI
Oxford
United Healthcare
UMR
Other
13
Secondary Member Identification Number* This field is required.Please Include the 3 letter Prefix if there is one
This is not the Insurance Policy Number
14
Uploading a picture of your insurance card will ensure efficiencyThe details on your card will help provide our experts with ALL the details we need.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
Should be Empty: