Gravity Test - Accurate Medical Billing

Provider*

Search by provider name, practice name, or city.

Patient's Name

Patient's Name*

Please provide the patient's name exactly as it's printed on their health insurance card.

First Middle Last

Mailing Address

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Contact Email Address

Contact Email Address*

Phone Contacts

Phone Number (Primary)*

Phone Type (Primary)

Phone Number (Alternate 1)

Phone Type (Alternate 1)

Phone Number (Alternate 2)

Phone Type (Alternate 2)

Patient's Date Of Birth

Patient's Date of Birth*

Please provide the patient's date of birth using the mm/dd/yyyy format.

Patient's Gender

Patient's Gender*

Patient's gender as recognized by the insurance company.

Male
Female

Insurance Information

Primary Insurance Information

Primary Insurance Company Name*

Member ID Number*

Group Number*

Is the patient the subscriber (policyholder)?*

Yes
No

Primary Insurance Subscriber

Subscriber's Name*

First Middle Last

Please provide the patient's name exactly as it's printed on their health insurance card.

Subscriber's Date of Birth*

Please provide the subscriber's date of birth using the mm/dd/yyyy format.

Relationship to Patient*

Does the subscriber live at the same address as the patient?*

No
Yes

Subscriber's Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Please provide the subscriber's mailing address, if it is different than the patient's address.

Primary Insurance ID Card Upload

Please upload a scan or photo of the patient's insurance ID card, front and back sides. Only JPG, JPEG, PNG, and PDF files accepted (maximum file size 5MB).

Primary Card Front:

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 5 MB.

Accepted types: jpg, jpeg, png, pdf (Max Size 5MB)

Primary Card Back:

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 5 MB.

Accepted types: jpg, jpeg, png, pdf (Max Size 5MB)

Does the patient have a secondary/supplemental insurance policy?*

No
Yes

Secondary/Supplemental Insurance Information

Secondary Insurance Company Name*

Secondary Insurance Member ID Number*

Secondary Insurance Group Number*

Is the patient the subscriber (policyholder) of the Secondary/Supplemental Insurance?*

No
Yes

Secondary Insurance Subscriber

Subscriber's Name*

First Middle Last

Please provide the patient's name exactly as it's printed on their health insurance card.

Subscriber's Date of Birth*

Please provide the subscriber's date of birth using the mm/dd/yyyy format.

Relationship to Patient*

Does the secondary insurance subscriber live at the same address as the patient?*

No
Yes

Secondary Subscriber's Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Please provide the subscriber's mailing address, if it is different than the patient's address.

Do you have a Secondary/Supplemental insurance card image you want to add?*

No
Yes

Secondary Insurance ID Card Upload

Please upload a scan or photo of the patient's secondary insurance ID card, front and back sides. Only JPG, JPEG, PNG, and PDF files accepted (maximum file size 5MB).

Secondary Card Front:

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 5 MB.

Accepted types jpg, jpeg, png, pdf (Max Size 5MB)

Secondary Card Back:

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 5 MB.

Accepted types jpg, jpeg, png, pdf (Max Size 5MB)

The information submitted on this page is being captured by Accurate Medical Billing, Inc. (AMB), a practice-management company contracted by your provider for this express purpose. This data might be used for the verification of insurance eligibility and benefits. Any verification performed by AMB is not a guarantee of coverage until claims associated with the services rendered by your provider have been processed by the insurance company. Thank you.

Privacy Policy

Accurate Medical Billing, Inc has confidentiality agreements in place with our contracted providers. Any data collected through this document will not be shared with any other entity besides your specific provider. A full copy of our privacy policy is available upon request or by viewing it at https://getamb.com/privacy-policy.

Consent*

I have read and understand the privacy policy and HIPAA policies associated with using this form.*

Comments

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

New Patient Portal TEST

Patient Portal

Patient's Name

Mailing Address

Contact Email Address

Phone Contacts

Patient's Date Of Birth

Patient's Gender

Insurance Information

Primary Insurance Information

Primary Insurance Subscriber

Primary Insurance ID Card Upload

Secondary/Supplemental Insurance Information

Secondary Insurance Subscriber

Secondary Insurance ID Card Upload

Privacy Policy