Service Selection
Service Category:
CARDIAC SERVICES
CT SCAN
EVALUATION & MANAGEMENT
IMAGING
LAB
MAMMOGRAPHY
MRI
NUCLEAR MEDICINE
OUTPATIENT PROCEDURES
SLEEP STUDY
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- MedicareComplete UnitedHealthCare
AARP- UnitedHealthCare Ovations AARP
ACS Benefit Services Inc.
Administrative Services Inc
Aetna
Aetna Administrator Medicare Supplement
Aetna Better Health (NE)
Aetna Medicare Supplement Insurance
Aetna Senior Supplemental
Affinity Health Plan
AFLAC - Medicare Supplemental
Alaska Electrical Health and Welfare
All Savers Life Insurance Co
Allegiance Benefit Plan Management
Allied Benefit Systems
Altius Health Plans Coventry
AmeriBen Solutions Inc
American Family Insurance
American Family Life Assurance Co AFLAC
American National Insurance Co ANICO
American Republic Insurance
American Retirement Life Ins Co MCR Sup
Arbor Health Plan
Assurant Health
Avera Health Plans
Bankers Life and Casualty
Blue Cross Blue Shield of CO
Blue Cross Blue Shield of IA Wellmark
Blue Cross Blue Shield of IL
Blue Cross Blue Shield of MN
Blue Cross Blue Shield of ND
Blue Cross Blue Shield of NE
Blue Cross Blue Shield of NM
Blue Cross Blue Shield of NY Empire
Blue Cross Blue Shield of SD Wellmark
Blue Cross Blue Shield of TN
Blue Cross Blue Shield of TX
Blue Cross of CA Anthem
Blue Shield of CA
Central States Health & Welfare Funds
Central States Indemnity
CHAMPVA - HAC
Cigna
CIGNA Healthspring MCR Adv
Colonial Penn Life
Continental General/Cigna MCR Supplement
CoOportunity Health - HealthPartners MN
Coventry Health Care
Coventry Health Care of Nebraska
Coventry Health Care USA
Coventry Health CareNet
Coventry Health Group Health Plan
Coventry Missouri
Cox Health Plan
Dakota Care
First Health
First Health Network
Gerber Life
Gilsbar Inc
Golden Rule Insurance Company
Government Employees Hospital Association (GEHA)
Great West Healthcare
Group Health Cooperative
Health Net National
Healthy Blue After 1/1/2021 (Wellcare NE)
Heartland National Life
Humana
Humana Advantage Care Plans Med Advantage
Kaiser Foundation Health Plan of Washington Option
Katy Medical Group
Liberty National Life Insurance Company
Loyal American Life Insurance Co - Cigna Supp
Magnolia Health Plan MCD Rep
Mail Handlers Benefit Plan
Medica
Medica IFB Medica2
Medicaid Iowa
Medicaid Minnesota
Medicaid Missouri InfoCrossings
Medicaid Montana
Medicaid Nebraska
Medicaid North Carolina
Medicaid Oklahoma
Medicaid South Dakota
Medicaid Wyoming
Medicare A Eligibility (all states)
Medico Insurance Company
Meritain
Meritain Health/CBSA
Mutual Health Services
Mutual of Omaha Insurance Company
NALC/Affordable
National Association of Letter Carriers NALC
Nationwide Health Plans
Nebraska Total Care MCD Rep
New ERA Life Insurance
Oxford Health Plans
Pacific Source Health Plan
PHCS Savility Payers
Physicians Mutual Insurance Company
Prime West
Reserve National Insurance
Sanford Health Plan
Security Health Plan
Standard Life and Accident Ins MWG 73099
State Farm Insurance Companies
TransAmerica Life Insurance Company 59222
Tricare For Life
Tricare North
Tricare West UHC Military and Veterans
UHC Community Plan NE
UHC Group Medicare Advantage
UMR United Medical Resources
UMR Wausau/UHIS
Union Pacific Railroad Employees Health Systems
United American Insurance Company
United Healthcare
United Teacher Associates Ins Co - Cigna Supp
University Family Care MCD Rep (Maricopa)
USAA auto only
VA Fee Basis Programs
VA Health Administration Center
VA Healthcare
Washington National
WebTPA
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: $)