Update & Billing Question Form
Insurance, Address, Email, Phone, Etc
MHP
Practice Name
Practice Billing Email
Date
-
Month
-
Day
Year
Date
Client First Name
Client Middlle Initial
Client Last Name
Email on file for billing
*
example@example.com
Account ID - found in email & on statement
Marital Status
Client Date of Birth
-
Month
-
Day
Year
Date
Check which below applies (one or more)
*
Update Insurance
Change Client Address
Change or Update Responsible Party Info
Ask Billing Question/Other
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Client Address Update
Client Address Update
Client Address 1
Client Address 2
Client City
Client State
Client Zip
Change Responsible Party or Update RP Information
Change Responsible Party or Update RP Information
It's only necessary to enter the information that has changed
RP First Name
RP Last Name
RP Address 1
RP Address 2
RP City
RP State
RP ZIp
Email
*
example@example.com
RP SSAN
RP DOB
-
Month
-
Day
Year
Date
The RP is the client's...
Please Select
Parent
Spouse
Child
Sibling
Grandparent
Grandchild
Parent In Law
Child In Law
Significant Other
Other
RP Gender
Please Select
Male
Female
Transgender-Male
Transgender-Female
Gender-Variant/Non-conforming
Other
Do not want to disclose
RP_REL
RP_GEND
Is the client insured
Add or Correct Insurance Policy
Add or Correct Insurance Policy
Who is the policy holder?
Client
Responsible Party
Other
Subscriber First Name
Subscriber Last Name
Subscriber Address 1
Subscriber Address 2
Subscriber City
Subscriber State
Subscriber Zip
Subscriber DOB
-
Month
-
Day
Year
Date
Subscriber SSAN
Subscriber Gender
Please Select
Male
Female
Transgender-Male
Transgender-Female
Gender-Variant/Non-conforming
Other
Do not want to disclose
The subscriber is the client's...
Please Select
Parent
Spouse
Child
Sibling
Grandparent
Grandchild
Parent In Law
Child In Law
Significant Other
Other
S1_REL
s1_GEND
Insurance Company
Please Select
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OPTUM UBH CLAIMS (87726)
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CIGNA (62308)
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MERITAIN HEALTH (41124)
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MEDICARE IOWA (IAMCR)
OTHER
Other Company Name
i1_insco
Member ID
Group
Employer
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