Insurance Form

While I am pleased to submit insurance claims as a courtesy to my patients, please note that you as the patient are responsible for payment should insurance fail to cover the visit for any reason. To avoid unpleasant surprises, please call your insurance company to obtain answers to all the questions below.

Patient Information

* Indicates required field

Last Name *

First Name *

Gender *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Marital Status *

Date of Birth *

ICD-10 Diagnosis Code *

Primary Insurance

Primary Insurance Company *

Referral required? *

Insurance ID Number *

Name of Referring Physician (if referral required) *

Name of Primary Insured *

Relationship to Primary Insured *

Address of Insured (if different from patient) *

Line 1

Line 2

City

State

Zip Code

Country

Date of Birth of Primary Insured (if different from patient) *

Front of Insurance Card *

Max file size: 20MB

Back of Insurance Card *

Max file size: 20MB

Secondary Insurance

Secondary Insurance Company *

Referral required? *

Insurance ID Number *

Name of Referring Physician (if referral required) *

Name of Primary Insured *

Relationship to Primary Insured *

Address of Insured (if different from patient) *

Line 1

Line 2

City

State

Zip Code

Country

Date of Birth of Primary Insured (if different from patient) *

Information to be Obtained from Insurance Company

Please call your insurance company to answer the questions below. Please ask for a reference number for your call and enter the number in the form below for future reference.

The following information may be helpful for your call:

My provider ID# is 1134161300

You will need a procedure code as well as a diagnosis code that your insurance covers
The procedure codes I use are 97802 and 97803
Many plans cover the diagnosis code: Z71.3 Contact me if you need help finding a covered diagnosis code.

Reference number for call to insurance company *

Does your insurance company cover your diagnosis? *

Does your policy cover procedure code 94690? *

How many nutrition visits are you entitled to? Over what time frame? *

Copay *

Deductible for Nutrition Counseling *

Remaining Deductible *

Submit