"I have new Insurance" -- Re-Verification Form

If you have new insurance, please immediately let the office know to cancel any upcoming appointments until you are re-verified so that you aren't responsible for the cost of the visit.

Please fill this form below so that the Biller can re-verify you

Also, please text us at 562-947-8832 or Spruce App CLEAR photos of the front & back of your card

Before your next appointment please make sure you call the Biller at 844-955-2616 to see if all your benefits are the same so that you are not responsible for the visit. (Please give them 5 business days after submitting the below before calling)

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CURRENT PATIENT First Name: *

CURRENT PATIENT Last Name: *

Date of Birth: *

Your Cell Phone Number *

Health Plan Name (i.e., United Healthcare, Blue Cross) *

Insurance ID# *

Tel # on back of Insurance Card for Providers or Eligibility *

SECONDARY Insurance Company

SECONDARY Insurance ID#

I am a current patient updating my insurance

I am a NEW patient, never been seen before by this office.

Your Mailing Address (Street, City, State, Zip) *

If you've been given an Auth, add the long Authorization #

If you've been given an Auth, add the 5-digit CPT Code (i.e. 90791 or 90792)

Medical Group (i.e. PIH Health/Applecare MG) *

Captcha (spam protection code) *

*

I hereby agree that my data entered in the contact form will be stored electronically, and will be processed and used for the purpose of establishing contact. I am aware that I can revoke my consent at any time.

Note: Fields marked with * are required