Service Selection
Service Category:
CARDIAC SERVICES
CT SCAN
EVALUATION & MANAGEMENT
INPATIENT SERVICES
LAB
MAMMOGRAPHY
MRI
OUTPATIENT PROCEDURES
SLEEP STUDY
ULTRASOUND
X-RAY
Service:
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Service Description:
Estimated Date of Service:
(MM/DD/YYYY)
Insurance Type:
All Payers
Government (Medicare and Medicaid only)
Commercial (Excludes Medicare and Medicaid)
Patient Information
Last Name:
First Name:
Date of Birth:
(MM/DD/YYYY)
Gender:
Male
Female
Unspecified
Address:
City:
State:
ZIP Code:
Phone Number:
Insurance Information
I have insurance and I know my information
I don't have Insurance
Insurance Selection:
Other Insurance
AARP- UnitedHealthCare Ovations AARP
Aetna
Aetna Administrator Medicare Supplement
Aetna Medicare Advantage
Allied Benefit Systems
American National Insurance Co ANICO
American Postal Workers Union APWU
Bankers Fidelity (Atlantic American)
Bankers Life and Casualty
Blue Cross Blue Shield of OH Anthem
Blue Cross Blue Shield of OH Anthem MCR Adv
Buckeye Community Health
Buckeye Community Health Plan MCR Adv
CareSource OH
Central States Indemnity
CHAMPVA - HAC
Cigna
CoreSource
Everence
Gerber Life
Golden Rule Insurance Company
Health Plan of Upper Ohio Valley
Humana
Humana Advantage Care Plans Med Advantage
Medicaid Ohio
Medical Mutual of Ohio
Medicare A Eligibility (all states)
Medico Insurance Company
Meritain Health/CBSA
Molina Healthcare of Ohio
Mutual of Omaha Insurance Company
NGS Coresource
Paramount Care
Physicians Mutual Insurance Company
Reserve National Insurance
Standard Life and Accident Ins MWG 73099
State Farm Insurance Companies
Sterling Investors Life Insurance
SummaCare Health Plan
TransAmerica Life Insurance Company 59222
Tricare East Region
Tricare For Life
UHC West (Pacificare) HMO AZ, CO, NV
UMR United Medical Resources
UMR Wausau/UHIS
United American Insurance Company
United Healthcare
Insurance Company Name:
Insurance Group Number:
Insurance Member ID Code:
Remaining
Deductible Amount:
(ex: $)
Copayment Amount:
(ex: $)
Coinsurance Percentage:
(ex: %)
Remaining
Out of Pocket Max:
(ex: $)