Health Insurance

Primary Insurance Information
Please complete all information below for your primary insurance. If you have secondary insurance, you will have the option to add that information before submitting your form.
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Policy Holder / Subscriber Name*

First NameLast Name
Policy Holder / Subscriber Date of Birth*

MonthDayYear
Date
Primary Insurance Provider*

AetnaAlwaysBlue Cross Blue ShieldBMC HealthNet PlanCignaHarvard PilgrimMassHealthTricareTuftsUniCareUnited HealthcareOther
Policy Effective Date (leave blank if unknown)

MonthDayYear
Date
Please provide your BMC Member ID*
We are working with BMC HealthNet to try and streamline the process for patients to switch to Dr. Hansen at Peak Pediatric Care. They are requesting each patients member ID typed out so that we can supply them with a full list.
Upload a photo showing the FRONT of your insurance card*

Cancelof
Upload a photo showing the BACK of your insurance card*

Cancelof
Do you have a secondary insurance policy?*

YesNo
Secondary Insurance Information
Is the policy holder the same as the primary insurance?*

YesNo
Policy Holder*

First NameLast Name
Secondary Insurance Provider*

AetnaAlwaysBlue Cross Blue ShieldBMC HealthNet PlanCignaHarvard PilgrimMassHealthTricareTuftsUniCareUnited HealthcareOther
Upload a photo showing the FRONT of your insurance card*

Cancelof
Upload a photo showing the BACK of your insurance card*

Cancelof
Do you have other children registered with Peak?*

YesNo
Do you have separate insurance ID number and/or cards for each child?*

Yes, each child has their own card and ID number.No, the ID number is the same and everyone is listed on the same card.
Since each child shares the same insurance ID number and card, you will not need to complete separate forms. Please list the full name and date of birth for each additional child below and then submit the form.*
You will need to submit separate forms for each child so that we have the correct insurance ID number on file in their account.

Please submit this form and you then be able to complete another form for the next child.
Should be Empty:

Primary Insurance Information

Secondary Insurance Information