Current Client- Insurance Update Form
Our billing team will update your account 24-48 hours after receiving your form.
First Name
*
Last Name
*
Date of Birth
*
Phone
Email
*
Termination Date of Current Insurance on File
*
New Primary Insurance Carrier
*
Aetna
ASR
Blue Cross Blue Shield PPO
Blue Care Network HMO
Cigna
Mclaren Commercial
Medicare Part B
Medicare Plus Blue
Medicaid: Blue Cross Complete
Medicaid: Mclaren
Medicaid: Meridian
Medicaid: Molina
Medicaid: Priority Health
Medicaid: United Health Care
Priority Health Commercial
Priority Health Narrow Network
Self Pay
United Healthcare Commercial
Other - note below
Insurance Carrier - Other
Insurance ID
*
Effective Date of New Policy
*
Do you have secondary insurance?
*
Yes
No
Secondary Insurance Carrier Name
Secondary Insurance Carrier ID Number
Is there a Coordination of Benefits for Secondary Policy on file with both insurance plans?
Yes
No
Unsure
Insurance Update Comments/Notes
By submitting, you agree to receive text messages at the provided number from Life Support LLC. Message frequency varies, and standard message and data rates may apply.
Yes, please contact me by my preferred method above
Please do not use text or email
You have the right to OPT-OUT receiving messages at any time. To OPT-OUT, reply "STOP" to any text message you receive from us. Reply HELP for assistance.
I understand I have the option to OPT-OUT at any time.
Submit