You can always press Enter⏎ to continue
Landing Page Part B
HIPAA
Compliance
1
User ID
Previous
Next
Next
Press
Enter
2
Health Insurance Information
*
This field is required.
Primary Insurance Company
Plan Name
Policy ID#
Group Number
Date of Birth
Previous
Next
Next
Press
Enter
3
Relationship to the Primary Subscriber
*
This field is required.
Doyou get Insurance Coverage from someone other than yourself?
Self
Spouse
Child
Other
Previous
Next
Next
Press
Enter
4
Primary Subscriber
Please enter primary subscriber's information
First Name
Last Name
Date of Birth
Email (if different than above)
Employer
Job title
Previous
Next
Next
Press
Enter
5
Primary Subscriber Employer
Employer
Job title
Previous
Next
Next
Press
Enter
6
Do you have secondary insurance?
Yes
No
Previous
Next
Next
Press
Enter
7
Secondary Health Insurance Information
Primary Insurance Company
Plan Name
Policy ID#
Group #
Previous
Next
Next
Press
Enter
8
Relationship to the Secondary Insurance Subscriber
*
This field is required.
Do you get Insurance Coverage from someone other than yourself?
Self
Spouse
Child
Other
Previous
Next
Next
Press
Enter
9
Secondary Insurance Subscriber
First Name
Last Name
Date of Birth
Email (if different than above)
Previous
Next
Next
Press
Enter
Should be Empty:
Question Label
1
of
9
See All
Go Back
Next