INSURANCE CARDS AND PHOTO ID

Shelby Counseling Associates, PSC
12701 Townepark Way Louisville, KY 40243
30 Stonecrest Court Shelbyville, KY 40065

Phone: 502-254-8880 Fax: 502-254-8870
ShelbyCounselingPSC@gmail.com
Client Name:*

First NameLast Name
Client DOB:*

MonthDayYear
Date
Primary Insurance MEMBER ID/Policy Number*
Primary Insurance Subscriber Name*

First NameLast Name
Relationship to Patient*
Subscriber DOB:*

MonthDayYear
Date
Subscriber SSN:*
Subscriber Employer:*
Do you have a secondary insurance?*

YesNo
Secondary Insurance MEMBER ID/Policy Number
Secondary Insurance Subscriber Name

First NameLast Name
Relationship to Patient
Subscriber Date of Birth:

MonthDayYear
Date
Subscriber SSN
Subscriber Employer

To take pictures of your cards, click here
Photo ID*
Primary Insurance card (front)*
Primary Insurance card (back)*
Secondary Insurance card (front)*
Secondary Insurance card (back)*

OR to upload files of your cards, click here
Photo ID

Browse Files

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Primary Insurance card (front)

Browse Files

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Primary Insurance card (back)

Browse Files

Cancelof
Secondary Insurance card (front)

Browse Files

Cancelof
Secondary Insurance card (back)

Browse Files

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Should be Empty: