Treatment Consent HIPAA Telehealth Informed Consent Service Agreement Medical History PCP Release of Information Adult Psychosocial Child Psychosocial Payment Authorization Document Submission Insurance Submission Appeal Submit or Update Insurance information Use this form if you did not have your insurance information available when you scheduled, if your insurance plan has changed, or if you need to submit secondary insurance information.Client's First Name* First Client's Last Name* Last Office Location*Choose OneBay CityGrosse PointeMidlandMount ClemensPort HuronSaginawHow would you like to submit your insurance information?*Choose OneSubmit ImagesSubmit DetailsSubmit Your ID Cards* Drop files here or Select files Max. file size: 256 MB, Max. files: 6. Please upload the following images: Insurance Card (Front and Back) & Drivers License or ID (Front and Back) * There is a maximum limit of six images.Client's Date of Birth* MM DD YYYY Phone*Email* Insurance TypePrimarySecondaryInsurance Provider*Choose OneBlue Cross Blue Shield of MichiganBlue Cross Blue Shield (Out-of-State)Blue Cross Network of MichiganAetnaCofinityCignaHAPHealth Alliance PlanHumanaMedicareMeridian MedicaidPriority HealthUnited Health Care CommercialUnited Health Care MedicaidOther (Please Specify)Insurance Company Phone Number*What's the name of your insurance?* Policy Group Number* Policy ID / Enrollee ID* Relationship to Insured*SelfSpouseChildPolicy Holder's First Name* First Policy Holder's Last Name* Last Policy Holder's Date of Birth* Month Day Year Copyright 2020 © Renewal Christian Counseling Center
