Service Selection
Service Category:
CARDIAC SERVICES
CT SCAN
EVALUATION & MANAGEMENT
INPATIENT SERVICES
LAB
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MRI
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ON HOLD FOR HISTORICAL DATA
OUTPATIENT PROCEDURES
READY FOR REVIEW
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- MedicareComplete UnitedHealthCare
AARP- UnitedHealthCare Ovations AARP
Aetna
Aetna Medicare Advantage
AmeriBen Solutions Inc
American Postal Workers Union APWU
AmeriGroup
Blue Cross Blue Shield of IL
Blue Cross Blue Shield of WV Highmark
Capitol Administrators
CareSource OH
CHAMPVA - HAC
Cigna
Cigna PPO
Coventry Health Care
CoventryCares of West Virginia MCD Rep
Globe Life & Accident Insurance Company
Golden Rule Insurance Company
Health Cost Solutions
Health Plan of Upper Ohio Valley
HealthSCOPE Benefits Inc
HealthSmart Benefit Solutions (Wells Fargo)
Humana
Humana Advantage Care Plans Med Advantage
Key Benefit Administrators
Medicaid West Virginia UNISYS
Medical Mutual of Ohio
Medicare A Eligibility (all states)
Meritain
Meritain Health/CBSA
Mutual of Omaha Insurance Company
National Association of Letter Carriers NALC
SAMBA Health Benefit Plan
Standard Life and Accident Ins MWG 73099
State Farm Insurance Companies
Tricare East Region
Tricare For Life
Tricare West UHC Military and Veterans
UHC Group Medicare Advantage
UMR United Medical Resources
UMWA Health & Retirement Funds
UNICARE
United American Insurance Company
United Healthcare
United Mine Wrkrs of Amrca Hlth Retirement Fnds
VA Healthcare
WebTPA
WellCare - FL SC
West Virginia Family Health 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: $)