Insurance Update

Insurance Update
Patient Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
CBI Provider Name(s):*
Date of Next Appointment:*

MonthDayYear
Date
IMPORTANT: Please note: CBI is NOT in network with any Medicaid/Medical Assistance insurance products, including but not limited to: CCBH, UPMC For You, United Community Plan, Aetna Better Health, Highmark Wholecare, Gateway, and VBH. Additionally, CBI is unable to accept Medicare/Medicaid DUAL plans.*

I understand CBI is not able to accept Medicaid/Medical Assistance insurance plans as listed above
IMPORTANT: Please note that CBI clinicians are INDIVIDUALLY credentialed, which means not all insurances are accepted by all providers at CBI. We will relay your new insurance information to our billing department for review, and they will contact you within a few business days to let you know if it can be accepted by your current provider(s) at CBI.*

I understand.
New Insurance Company Name: (ex: UPMC, Highmark, Aetna, etc)*
Insurance Phone Number:*
Please enter a valid phone number.
Member ID#*
Group#*
Effective/Start Date of Plan:*

MonthDayYear
Date
Policyholder Relationship to Patient*

SelfParent/GuardianSpouseOther
Policyholder Name:
Policyholder Date of Birth:

MonthDayYear
Date
Please upload a copy of the FRONT AND BACK of your insurance card:*

Cancelof
Do you have secondary commercial insurance?*

YesNo
Secondary Insurance Company Name: (ex: UPMC, Highmark, Aetna, etc)
Secondary Insurance Phone Number:
Please enter a valid phone number.
Secondary Insurance Member ID#
Secondary Insurance Group#
Secondary Insurance Policyholder Relationship to Patient

SelfParent/GuardianSpouseOther
Secondary Insurance Policyholder Name:
Secondary Insurance Policyholder Date of Birth:

MonthDayYear
Date
Please upload a copy of the FRONT AND BACK of your secondary insurance card:

Cancelof
Signature of Patient (or Legal Guardian completing this form):*

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