Billing Information Form
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1
2Billing Information
Practitioner/Clinic Name: ____________________
(page 1 of 2)
Contact Information: ________________________
Patient Information
Name: ___________________________________________________
Date: _______________
Address: __________________________________________________________________________________
Phone: ___________________________________
Email: ____________________________________
Gender: ____________
Marital status: _____________
Date of birth: _________________
Social security number: _________________________
Date of injury: ________________
Referring healthcare provider: _________________________________________________________________
Phone: ___________________________________
Email: ____________________________________
Address: __________________________________________________________________________________
Primary Insurance Information
(e.g., Car Insurance if an auto accident, Worker’s Comp if an on-the-job injury, Health Insurance if an illness, etc.)
Insurance company: ______________________________________
Phone: _____________________
Address: _________________________________________________________________________________
Insurance ID# (include alpha prefix): _____________________
Group Plan #: _______________________
Name of insured (if other than you): _____________________________________________________________
Relationship to insured: __________________________
Insured’s SS#: ______________________________
Insured’s date of birth: ___________________________
Insured’s gender: ____________________________
Adjuster’s name: ________________________________ Phone: ________________ Fax: _______________
Secondary Insurance Information (if applicable)
Insurance company: ______________________________________
Phone: _____________________
Address: _________________________________________________________________________________
Insurance ID# (include alpha prefix): _____________________
Group Plan #: _______________________
Name of insured (if other than you): _____________________________________________________________
Relationship to insured: __________________________
Insured’s SS#: ______________________________
Insured’s date of birth: ___________________________
Insured’s gender: ____________________________
Adjuster’s name: ________________________________ Phone: ________________ Fax: _______________
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Parent category: Business