Insurance Submission| Renewal Christian Counseling Center

"*" indicates required fields

Use this form to submit a photocopy of your insurance information.

Client's First Name*

Client's Last Name*

Phone*

Email*

Client's Date of Birth*

Office Location*

How would you like to submit your insurance information?*

- Please allow this app to access your camera. - Please take individual images of both: 1. Drivers License or ID 2. Insurance Card FRONT and BACK

Driver's License or ID (FRONT)*

Drop files here or

Max. file size: 256 MB.

Driver's License or ID (BACK)*

Drop files here or

Max. file size: 256 MB.

Insurance Card (FRONT)*

Drop files here or

Max. file size: 256 MB.

Insurance Card (BACK)*

Drop files here or

Max. file size: 256 MB.

Insurance Type

Insurance Provider*

Policy ID / Enrollee ID*

Policy Group Number*

Insurance Company Phone Number

Relationship to Insured*

First Name of Insured (If other than self)*

Last Name of Insured (If other than self)*

Policy Holder's Date of Birth*

Name

This field is for validation purposes and should be left unchanged.