Service Selection
Service Category:
CARDIAC SERVICES
CT SCAN
EVALUATION & MANAGEMENT
IMAGING
INPATIENT SERVICES
LAB
MAMMOGRAPHY
MRI
NUCLEAR MEDICINE
OUTPATIENT PROCEDURES
SLEEP STUDY
ULTRASOUND
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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
AARP- MedicareComplete UnitedHealthCare
AARP- UnitedHealthCare Ovations AARP
Aetna
Aetna Administrator Medicare Supplement
Aetna Better Health (IL) MMAI
Aetna Medicare Advantage
All Savers Life Insurance Co
Allied Benefit Systems
AmeriBen Solutions Inc
American Family Insurance
American Family Life Assurance Co AFLAC
American Medical Security AMS
American Postal Workers Union APWU
American Republic Insurance
AmeriGroup
Amerihealth
APWU Health Plan
Assurant Health
Bankers Life and Casualty
Blue Cross Blue Shield of IL
Blue Cross Blue Shield of NY Empire
Cariten Healthcare
CHAMPVA - HAC
Cigna
Cigna PPO
Claims Management Services
CoreSource
Coventry Health Care
Dean Health Plan
Everence
First Health Network
Gerber Life
Golden Rule Insurance Company
Government Employees Hospital Association (GEHA)
Group & Pension Administrators
Health Alliance Medical Plans
HealthSCOPE Benefits Inc
HealthSmart Benefit Solutions (Wells Fargo)
Humana
Humana Advantage Care Plans Med Advantage
IlliniCare MCD Rep DOS prior to 120120
JP Farley Corporation
Kaiser Foundation Health Plan of Colorado
Loyal American Life Insurance Co - Cigna Supp
Mail Handlers Benefit Plan
Medicaid Arizona AHCCCS
Medicaid Arkansas
Medicaid Illinois
Medicare A IL J6
Medicare B IL J6
Medico Insurance Company
Meridian Health Plan of IL MCD DOS lt 01012020
Meritain
Meritain Health/CBSA
Molina Healthcare of IL MCD Rep
Mutual of Omaha Insurance Company
PHCS Savility Payers
Physicians Mutual Insurance Company
Reserve National Insurance
Royal Neighbors of America
State Farm Insurance Companies
Todays Options
TransAmerica Life Insurance Company 59222
Tricare East Region
Tricare For Life
Tricare West UHC Military and Veterans
Trustmark Insurance Company
Tufts Health Plan
UHC Community Plan TN MCD
UHC Plan of River Valley
UMR United Medical Resources
UMWA Health & Retirement Funds
UNICARE
United Healthcare
United HealthCare Life Insurance Co
VA Fee Basis Programs
Washington National
WebTPA
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: $)