Insurance Changes
Email address *
Name (Last, First)
Your answer
Date of Birth:
Your answer
Mobile phone #:
Your answer
Have you lost insurance? If so, what is the name of the insurance and what date did it expire?
Your answer
Have you gotten new insurance?
Remember, Eilis Clark MD LLC does not accept Medicare or Medicaid. If your insurance provides out-of-network benefits, we will file your claim, but you will need to pay what insurance does not cover at the time of the visit. If you do not have out-of network benefits (ex HMO), your insurance will not pay for your services from Eilis Clark MD LLC. Please bring your insurance card(s) to the visit if you want to use insurance. If your have new insurance and wish to use it, please continue. Otherwise, please skip to the bottom and click "Submit"
Primary Insurance Name (the full name)
Your answer
If you are not sure about the following answers regarding your insurance benefits, please call the phone number on your insurance card for assistance with the answers.
Type of Insurance
Group #
Your answer
ID #
Your answer
Effective Date of Coverage
MM
/
DD
/
YYYY
Address of Insurance Company City, State Zip
Your answer
Phone # for Insurance Company (for Providers)
Your answer
Website of insurance company
Your answer
Name of Guarantor/Sponsor (if it is not you)
Your answer
Address of Guarantor/Sponsor (if it is not you), including City, State, Zip
Your answer
Phone # of Guarantor/Sponsor (if it is not you)
Your answer
Date of Birth of Guarantor/Sponsor (if it is not you)
MM
/
DD
/
YYYY
My annual deductible is $
Your answer
My annual deductible is $
Your answer
I have paid this much of the deductible this year : $
Your answer
My copay type for OUT-OF-NETWORK visits is:
The copay amount ($ or %) for OUT-OF-NETWORK physician (MD) visits is:
Your answer
My insurance requires prior authorization for OUT-OF-NETWORK physician (MD) visits:
The Authorization Number number for this OUT-OF-NETWORK physician (MD) is:
Your answer
The copay amount ($ or %) for OUT-OF-NETWORK mental health therapy visits is:
Your answer
Secondary Insurance Name (the full name)
Your answer
If you are not sure about the following answers regarding your insurance benefits, please call the phone number on your insurance card for assistance with the answers.
Type of Insurance
Group #
Your answer
ID #
Your answer
Effective Date of Coverage
MM
/
DD
/
YYYY
Address of Insurance Company City, State Zip
Your answer
Phone # for Insurance Company (for Providers)
Your answer
website of insurance company
Your answer
Name of Guarantor/Sponsor (if it is not you)
Your answer
Address of Guarantor/Sponsor (if it is not you), including City, State, Zip
Your answer
Phone # of Guarantor/Sponsor (if it is not you)
Your answer
Date of Birth of Guarantor/Sponsor (if it is not you)
MM
/
DD
/
YYYY
I have paid this much of the deductible this year : $
Your answer
My copay type for OUT-OF-NETWORK visits is:
The copay amount ($ or %) for OUT-OF-NETWORK physician (MD) visits is:
Your answer
My insurance requires prior authorization for OUT-OF-NETWORK physician (MD) visits:
The Authorization Number number for this OUT-OF-NETWORK physician (MD) is:
Your answer
The copay amount ($ or %) for OUT-OF-NETWORK mental health therapy visits is:
Your answer
I understand that my insurance is a contract between myself, my insurance company, and my employer if purchased through work. I am responsible for all costs not covered by insurance. I understand that OUT-OF-NETWORK insurance does not cover all of the costs of a visit.
Submit
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