Insurance Information – Reverification

To prevent unexpected, high patient balances, it is critical that we have your updated insurance information, including address, primary insurance insurance, and secondary insurance information. Please fill out the form below to update our systems and protect you against higher balances.

  • Basic Information

    Billing claims with the wrong demographic information results in denials and high patient balances.
  • Primary Insurance Information

    If we do not have up-to-date insurance information, we cannot bill claims correctly, and this results in high, unexpected patient balances.
  • Date Format: MM slash DD slash YYYY
  • Secondary Insurance Information (if applicable)

    If you have additional health insurance coverage, we must know about it in order to bill claims correctly. Failure to disclose can result in unexpected, high patient balances.
  • If you have additional insurance coverage and you do not let us know, it can significantly impact your balance. We must know of all your health insurances.
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.