Insurance Information

Person responsible for primary insurance - Please out completely

Today's Date:

Name of current insurance policy:

Name of the patients and date of birth covered under this policy:

Subscriber last name:

First Name:

Date of Birth:

Relationship to patient:

Same as patient:

Address:

City:

State:

Zip code:

Primary phone:

Alt phone:

An up-to-date copy of the patient's insurance card is required to bill you insurance, even if there are not any known changes! We are required to verify all insurance policies presented.

Front

Back

Please upload both the front AND back of the patient's insurance card(s). You may also email and/or text a copy to (248) 360-9241. If you are unable to upload or send the insurance cards prior to the appointment, please bring the insurance card with you to the appointment, and we will be happy to make a copy. Our email for any updates is updates@edgewoodspeds.com.

Are any of the above patients covered under a secondary insurance policy

Secondary Insurance: (if applicable)

Insurance Name:

Subscriber name:

Date of birth:

Relationship to patient:

Name of children covered under this policy:

Address:

City:

State:

Zip code:

Phone:(home or cell?)

Alt phone:(home or cell?)

Secondary Insurance Policy:

Front

Back

Please be aware we are unable to bill any MEDICAID policy as secondary insurance.

Signature of parent/guardian filling out form

Printed name

Date