Healthcare Financial Services, LLC - Professional Collections and Telemarketing.

PRIMARY / SECONDARY INSURANCE FORM

Please select the form used :
Primary Insurance
Secondary Insurance
Medicare
Medicaid
Medicare HMO

Primary Insurance – Note: All fields must be filled in for proper processing
Patient Name:
Phone #:
Email:
Client Account # (see letter):
Social Security #:
Address:
City:
State:
Zip:
Employer:
Primary Insurance:
Insurance Address:
City:
State:
Zip:
ID #:
Group #:
Insured Name on insurance card:
Insured Date of Birth:
Relationship to Patient:
Insured Place of Employment:
Policy Type:

Secondary Insurance:
Secundary Insurance:
Phone #:
Insurance Address:
City:
State:
Zip:
ID #:
Group #:
Insured Name on insurance card:
Insured Date of Birth:
Relationship to Patient:
Insured Place of Employment:
Policy Type:

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