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
Submit