Hope & Faith Wellness Clinic - Insurance Forms
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Email *
Patient Full Name: *
Primary Insurance Company: *
Subscriber ID # (including letters): *
Group Number: *
$Co-pay: *
Secondary Insurance Company: *
Subscriber ID Number (including letters): *
Group Number *
Insurance Policyholder Full Name: *
Insurance Policyholder DOB: *
MM
/
DD
/
YYYY
Insurance Policyholder Address: *
Insurance Policyholder Relationship: *
Insurance Policyholder SSN: *
Insurance Policyholder Gender: *
PATIENT AUTHORIZATION
I authorize the release of any medical and insurance information necessary to process any claim.
*
Required
Managed Care / HMO Patients
I understand that it is my responsibility to obtain a valid referral from my primary care
physician, if a referral is required by my insurance plan. I understand that if I do not obtain or
have a referral on file that I may be held financially responsible for services received. I further
understand that I am responsible for services that are considered non-covered expenses by
my insurer.
*
Required
CARD DETAILS
Credit Card on File
Credit Card Full Name: *
Credit Card Full Number: *
Expiration Date: *
Security code: *
(e.g. 3 Digits for Visa, 4 Digits for AMEX)
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