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Secondary Insurance Information
Please Provide Secondary Health Insurance Card Images OR Enter Information manually
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Upload/Capture
Front of the Card
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Upload/Capture
Back of the Card
Success Message
Health / Medical Insurance Details
Insurance Payer Type
Medicare
Tricare
*
Enter
Payer Name
Required
EDI/Claims Payer ID
*
Enter
Subscriber/ Member ID
Required
Primary Group Number
Prescription Drug Insurance Details
RxBin
RxPCN
RxID
RxGroup
*
Select
Insured / Subscriber Relationship to Patient
Required
Self
Other
*
Enter
First Name
*
Enter
Last Name
*
Select
Gender
Male
Female
Other
Date of Birth
(mm/dd/yyyy)
Click on the checkbox,Use Patient address same as Subscriber / Insured
*
Enter
Address Line 1
*
Enter
City or Town
*
Enter
State or Province
*
Enter
Postal Code
*
Do you have Secondary Medical / Health Insurance coverage ?
Yes
No
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