Insurance Update Step 1 of 4 25% Client Name(Required) First Last Client Date of Birth(Required) MM slash DD slash YYYY Date of Next Appointment(Required) MM slash DD slash YYYY Provider Name(Required) Primary InsurancePrimary Insurance Company Name(Required) Primary Insurance Company Phone Number(Required)Member ID Number(Required) Group ID Number(Required) Effective/Start Date of Insurance(Required) MM slash DD slash YYYY Policy Holder Name(Required) First Last Policy Holder Date of Birth(Required) MM slash DD slash YYYY Client relationship to policy holder(Required) If the client is the policy holder, please write "self"Please upload a photo of your insurance card. This really helps our staff know if your insurance can be accepted.Front of CardMax. file size: 50 MB.Back of CardMax. file size: 50 MB.Do you have secondary insurance?(Required) No Yes Secondary InsuranceSecondary Insurance Company Name(Required) Secondary Insurance Company Phone Number(Required)Member ID Number(Required) Group ID Number(Required) Effective/Start Date of Insurance(Required) MM slash DD slash YYYY Policy Holder Name(Required) First Last Policy Holder Date of Birth(Required) MM slash DD slash YYYY Client relationship to policy holder(Required) If the client is the policy holder, please write "self"Please upload a photo of your insurance card. This really helps our staff know if your insurance can be accepted.Front of CardMax. file size: 50 MB.Back of CardMax. file size: 50 MB.Do you have tertiary insurance?(Required) No Yes Tertiary InsuranceTertiary Insurance Company Name(Required) Tertiary Insurance Company Phone Number(Required)Member ID Number(Required) Group ID Number(Required) Policy Holder Name(Required) First Last Policy Holder Date of Birth(Required) MM slash DD slash YYYY Client relationship to policy holder(Required) If the client is the policy holder, please write "self"Please upload a photo of your insurance card. This really helps our staff know if your insurance can be accepted.Front of CardMax. file size: 50 MB.Back of CardMax. file size: 50 MB. Not all insurances are accepted by all providers at CBI. We will relay your new insurance information to our billing department for review. They will contact you within a few business days to let you know if it can be accepted.
