Insurance Information Update

Patient Name

Patient Date of Birth

Address

City

State

Zip

Updated Insurance Information

Name of Primary Insurance Company

Name of Subscriber on the Insurance Card

Address of Primary Insurance Company

Policy Effective Date

Policy ID#:

Group ID#:

Subscriber's Date of Birth:

Subscriber's Home Address

Subscriber's Phone Number:

Subscriber's Relation to Patient

Subscriber's Employer

Add Additional Insurance Information

Responsibility for Payment for Services Rendered

By signing below, I hereby authorize Bloomington Pediatrics to submit claims for services rendered to the insurance company/companies listed by me. I authorize the release of protected health information to said insurance companies for the processing of claims. I understand that I am responsible for payment of services rendered and agree to pay any fees for services not covered by insurance, including, but not limited to co-insurance and deductible amounts. I agree to pay at the time of service any co-payment required by my insurance. I also understand I will be held responsible for the payment of any collection fees should my account be sent into collection proceedings.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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