Patient Full Name Patient Date of Birth Subscriber Full Name Subscriber Date of Birth Subscriber Relationship to Patient Self Spouse Parent Mailing Address Contact Phone Number Contact Email Photo/Scan of FRONT of Insurance Card Photo/Scan of BACK of Insurance Card Disclaimer I understand this request will produce a summary of plan benefits and is not intended to be a contract. Actual coverage will be determined when the claim is processed subject to all contract terms, including, but not limited to, member benefits, benefit maximums and deductibles on the date of service. This is not a pre-determination of benefits or a guarantee of payment. Send
