Insurance Change Request Form

JORDAN WEST FAMILY COUNSELING

INSURANCE CHANGE REQUEST FORM
PATIENT INFORMATION
Client Name
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
UPDATED PRIMARY PAYMENT SOURCE
Payment Source (Insurance, EAP, other)
Please provide the name of the EAP or Insurance company
Phone Number (Insurance, EAP, other)
Payment Source Address City, State, Zip
Authorization Number, If yes please provide AUTHORIZATION NUMBER
AUTHORIZATION NUMBER
Insured Name
Insured Date of Birth (for authorization purposes)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insured Address: City, State, Zip
PLEASE UPLOAD A COPY OF NEW INSURANCE CARD (FRONT AND BACK)

Browse Files

Cancelof
Include a copy of the FRONT and BACK sides of the Insurance Card.
I, the undersigned, certify that I (or my dependent) have insurance coverage with
Name of insurance company, EAP , or other
and assign directly to my provider all insurance benefits otherwise payable to me for services rendered. I understand that I am ultimately responsible for all charges accumulated. I hereby authorize Jordan West Family Counseling to release all information necessary to secure the payment of benefits, and authorize the use of this signature on all insurance submissions.
Patient Name
Relationship to Patient
Authorized Person
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDateHourMinutesAM/PM Option
Should be Empty:

JORDAN WEST FAMILY COUNSELING