Updated Demographics Client Name Required Date of Birth Required Address (Street, City, State, Zip) Phone Required Cell Phone Required Email Address Required Insurance Company Name Policy/Member Number Group Number SS# of Policy Holder Relationship of Policy Holder to Client Policy Holder's Date of Birth Policy Holder's Place of Employment Policy Holder's Address (Street, City, State, Zip) By submitting this form, I authorize release of any medical or other information to my insurance company as necessary to obtain payment in compliance with the Health Insurance Privacy and Portability Act (1996). Required I Agree Please type the letters and numbers shown in the image. Click the image to see another captcha.
