Service Selection
Service Category:
Ambulatory Surgery
Cardiac Rehab
CARDIAC SERVICES
Clinic
CT Scan
Doppler/Echo
Emergency Room
EVALUATION & MANAGEMENT
LAB
MRI
NUCLEAR MEDICINE
OUTPATIENT PROCEDURES
Physical Therapy
SLEEP STUDY
Specialty Clinic
Ultrasound
X-RAY
Service:
Please choose a service category
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
AARP- UnitedHealthCare Ovations AARP
Aetna
Aetna Administrator Medicare Supplement
Aetna Better Health (NE)
Aetna Senior Supplemental
All Savers Life Insurance Co
Allianz Life Insurance Co of NY
Allied Benefit Systems
American General
American Republic Insurance
Americo Financial Life & Annuity
APWU Health Plan
Assurant Health
Bankers Life and Casualty
Blue Cross Blue Shield of NE
Bright Health Plan
Bright Health Plan MCR Adv
Central Reserve Life MCR Sup - Cigna Supp
CHAMPVA - HAC
Cigna
Cigna PPO
Continental General/Cigna MCR Supplement
Coventry Health Care
Coventry Health Care of Nebraska
CoventryOne
First Health
Golden Rule Insurance Company
Government Employees Hospital Association (GEHA)
Healthy Blue After 1/1/2021 (Wellcare NE)
Key Benefit Administrators
Loyal American Life Insurance Co - Cigna Supp
Mail Handlers Benefit Plan
Medica
Medica Dual Solution Med Advntg
Medica IFB Medica2
Medicare A Eligibility (all states)
Medico Insurance Company
Mutual of Omaha Insurance Company
National Association of Letter Carriers NALC
Nebraska Total Care MCD Rep
Physicians Mutual Insurance Company
QualCare, Inc. PID 23342
Reserve National Insurance
Standard Life and Accident Ins MWG 73099
State Farm Insurance Companies
Tricare West UHC Military and Veterans
UHC Community Plan NE
UHC Group Medicare Advantage
UHC MAMSI, Optimum Choice, MDIPA
UHC MedicareComplete
UMR Wausau/UHIS
Unified Life Insurance Company
United Healthcare
Wellcare Health Plan Inc Encounters
WellCare Health Plan MCD Rep
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: $)