subject_line
Right to Receive a Good Faith Estimate of Expected Charges
Secure Insurance Card Form
Secure Secondary Insurance Card Form
To send us your insurance information, please complete this form.
You may find it easiest to complete this form on your smartphone as photos of your insurance card are required.
Your First Name
*
Your Last Name
*
Your Email Address
*
🛈
Your Phone Number
🛈
Please acknowledge that emails and text messages should not contain sensitive information.
*
🛈
I understand that emails and text messages are inherently insecure, could possibly be read by third parties, and should not contain sensitive information.
Your Date of Birth
*
🛈
+
Your Gender According to Insurance
*
🛈
Female
Male
Are you an existing client?
*
Yes
No
Do you have secondary insurance?
*
No
Yes
Please refer to your physical insurance card when populating the remaining fields.
Insurance Company
*
Insurance Company Phone Number
*
🛈
Member ID
*
To help prevent billing errors, please upload photos of the front and back of the insurance card (two photo files) below.
Insurance Card Photos
*
🛈
Are you the insurance plan subscriber?
*
🛈
Yes
No
What is your relationship to the insurance plan subscriber?
*
Child
Parent
Partner
Spouse
Other
Other
Subscriber First Name
*
Subscriber Last Name
*
Subscriber Street Address
*
Subscriber City
*
Subscriber State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Subscriber Zip Code
*
Subscriber Phone Number
*
🛈
Subscriber Date of Birth
*
🛈
+
Subscriber Gender According to Insurance
*
🛈
Female
Male
THE COMPASSION PRACTICE
447 BROADWAY • FLOOR 2 • NEW YORK, NY 10013
compassionify.com
•
(347) 391-0086