Registeration

Patient Billing Registration Form

Please upload front & back of insurance cards & Photo ID for accuracy of verification of benefits.

***INSURANCE DISCLAIMER***

Eligibility & Verification of benefits.

Thís is not a guarantee of payment, but an estimate. Actual payment and member responsibility are determined when claims are processed and may be different due to a number of factors including differences in services rendered, changes in patient eligibility, other payments made, provisions of the plan including recent amendments, applicable law, and other relevant factors.

PLEASE SELECT PREFERRED PROVIDER *

Patient Name *

First Name Middle Name / MI Last Name

Patient Date of Birth *

Date

Patient Social Security

Patient Address *

Street Address

Street Address Line 2

City State

Zip

Phone Number *

Email *

example@example.com

Guarantor Name (If not the same as Patient or Policy Holder)

First Name Middle Name / MI Last Name

Guarantor Date of Birth

Date

Guarantor Social Security

Guarantor Address

Street Address

Street Address Line 2

City State

Zip

Guarantor Phone Number

Guarantor Email

example@example.com

Primary Insurance Name

Primary Policy Holder Name

Primary Policy Holder Address

Street Address

Street Address Line 2

City State

Zip

Policy Holder Date of Birth *

Date

Policy Holder Social Security

Primary Subscriber/ Member ID Nbr *

Primary Group Nbr

Employer

Secondary Insurance Name

Secondary Policy Holder Name

Secondary Policy Holder Date of Birth

Date

Secondary Policy Holder Social Security

Secondary Policy Holder Address

Street Address

Street Address Line 2

City State

Zip

Secondary Subscriber/Member ID Nbr

Secondary Group Nbr

Employer

I agree that the Provider listed above billing department is authorized to submit insurance claims and follow up on insurance payments on behalf of my provider.

For Billing or Insurance questions please call 616-303-0660 or email billing@noblehealthcaresolutions.com

Mon-Wed 9am until 5pm Thursday 3pm until 7pm Fri 10 am unitl 2pm

Signature *

Clear

Name *

First Name Last Name

Date *

Date

File Upload Insurance Card & Photo ID *

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