Client Insurance Information "*" indicates required fields Need to get insurance information to us? Please provide the details below. In the event your insurance coverage changes, you need to notify us immediately. Not all services are covered benefits in all contracts. Some insurance companies select certain procedures or diagnoses that they will not cover. Knowingly giving false insurance information can result in insurance fraud. Contact Phone Number:*If there are questions about the information submitted, we will call to follow up. Please provide the telephone number that we can best reach you. Client InformationPlease submit siblings seperatelyClient's Legal First Name* Client's Legal Last Name* Client's Date of Birth* Insurance CardsAttach a copy of each insurance card, including both the front and back:Attach a copy of each insurance card, including both the front and back: Drop files here or Select files Accepted file types: jpg, gif, pdf, , Max. file size: 512 MB. Insurance Type(s)Insurance Type (select all that apply):* No Insurance, will be self pay Commercial Insurance Medicaid/Badgercare Medicaid/BadgercareID Number: Effective Date: Commercial InsuranceCommerical Health Insurance Company Name: Member ID Number: Group Number: Effective Date: Subscriber's Full Name: Subscriber's Date of Birth: Subscriber's Gender:Make SelectionMaleFemaleSubscriber's Relationship to Patient: Subscriber's Employer: Subscriber's Address: Street Address Mailing Address (if different than street address) City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Additional Commercial InsuranceIs the patient covered under a secondary commercial insurance?* Yes No Commercial Health Insurance Company Name: Member ID Number: Group Number: Effective Date: Subscriber's Full Name: Subscriber's Gender:Make SelectionMaleFemaleSubscriber's Date of Birth: Subscriber's Relationship to Patient: Subscriber's Employer: Subscriber's Address Street Address Mailing Address (if different than street address) City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code If more than one insurance, which is primary and secondary? Employee Assistance Program (EAP)Do you have an Employee Assistance Program (EAP) Authorization?Make SelectionNoYesEAP Authorization Number: EAP Effective Date: Number of visits covered by EAP authorization: HiddenHIPAA Forms Plugin Email