COPY OF Direct Billing Form

Required Field

Personal Info

First Name

Last Name

Date of Birth (MM/DD/YYYY)

Contact Info

Review & Agree

Clinic Policy (Review Required)

You need to review and accept this before submitting

Signature

Policy Holder Birthdate

Insurance

I have insurance

Insurer

Policy Name

Policy / Group / Plan #

Member ID / Certificate #

Policy Holder

I'm not the policy holder.

First Name

Last Name

Relationship To Patient

Date of Birth

Address

City

Prov / State

Postal / Zip Code

Phone Number