Service Selection
Service Category:
GI Lab
Inpatient
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MRI
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Outpatient Misc
Radiology
Sleep Lab
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Wound Care Center
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 Better Health (OH)
Aetna Medicare Advantage
Aetna Senior Supplemental
All Savers Life Insurance Co
Allegiance Benefit Plan Management
Allied Benefit Systems
American Republic Insurance
AmeriGroup
Bankers Fidelity (Atlantic American)
Bankers Life and Casualty
Behavioral Health Systems
Blue Cross Blue Shield of AK
Blue Cross Blue Shield of AL
Blue Cross Blue Shield of MO Anthem
Blue Cross Blue Shield of TN
Blue Cross Blue Shield of TX
Buckeye Community Health
CareSource OH
Central Reserve Life MCR Sup - Cigna Supp
CHAMPVA - HAC
Cigna
CIGNA Healthspring MCR Adv
Covenant Administrators Inc Atlanta GA
Gilsbar Inc
Golden Rule Insurance Company
Government Employees Hospital Association (GEHA)
Group & Pension Administrators
Health Cost Solutions
Healthgram Inc
HealthSCOPE Benefits Inc EHC Repricing
HealthSmart Benefit Solutions
HealthSpring HMO Medicare+Choice
Humana
Humana Advantage Care Plans Med Advantage
Mail Handlers Benefit Plan
Medicaid Alabama
Medicaid Arizona AHCCCS
Medicaid Florida
Medicaid Georgia
Medicaid Tennessee TennCare
Medicare A Eligibility (all states)
Medico Insurance Company
Meritain Health/CBSA
Mutual of Omaha Insurance Company
National Association of Letter Carriers NALC
Oxford Health Plans
Peach State Health Plan
Physicians Mutual Insurance Company
Planned Administrators Inc PAI
State Farm Insurance Companies
Tricare East Region
Tricare For Life
Tricare South
UHC Medicare Solution
UHC MedicareComplete
UMR United Medical Resources
UMR Wausau/UHIS
UMWA Health & Retirement Funds
United Healthcare
VA Health Administration Center
VIVA Health Plan
WebTPA
Wellcare Health Plan Inc MCR Adv
Windsor Medicare Extra
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: $)