INSURANCE INFORMATION

IMPORTANT INFORMATION REGARDING INSURANCE PLANS

Please note that Texas Modern Gastroenterology does NOT accept Medicaid insurances as a primary or secondary plan. These include Medicaid plans such as Traditional Medicaid, STAR, AmBetter, Superior Plans,

First Name

Last Name

Date of Birth

Do you have HMO Insurance?

Yes

PLEASE NOTE THAT IF YOU HAVE HMO INSURANCE, YOU WILL NEED A PRIOR AUTHORIZATION TO SEE US. THIS CAN BE OBTAINED BY CALLING YOUR PRIMARY CARE PROVIDER'S OFFICE AND OBTAINING THIS APPROVAL FROM YOUR INSURANCE COMPANY DIRECTLY.

Please upload a photo of the front of your insurance card

Add file

Please upload a file

Please upload a photo of the back of your insurance card

Add file

Please upload a file

Please upload a photo of the front of your secondary/supplemental insurance card

Add file

Please upload a file

Please upload a photo of the back of your secondary/supplemental insurance card

Add file

Please upload a file

Your information will be encrypted.