New Patient Portal

For the best browser experience, this portal functions optimally using desktop versions of Google Chrome or Firefox.

    Name of provider

    Firefox or Chrome: search by provider name, practice name, or city.
    Other browsers: enter provider name.


    Patient's Name

    First
    M.I.
    Last

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


    Mailing Address

    Street Address
    Address Line 2

    :

    City
    State
    ZIP

    Contact Email Address

    Email

    Phone Contacts

    Only one is required. Please enter with no spaces or special characters.

    Primary Phone
    Phone Type:

    :

    Alternate Phone
    Phone Type:

    :

    Alternate Phone
    Phone Type:

    :


    Patient's Date of Birth

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

    :


    Patient's Gender

    Please select one:


    Please enter your insurance information below.

    Insurance Information

    Primary Insurance Company Name
    Member ID Number
    Group Number
    Is the patient the subscriber (policyholder)? YesNo
    Subscriber Name

    First
    M.I.
    Last
    Subscriber Date of Birth
    Relationship to Patient
    Does the subscriber live at the same address as the patient? YesNo
    Please provide the subscriber's mailing address.
    Street Address
    Address Line 2
    City
    State
    ZIP

    Please enter the subscriber's mailing address.


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

    Secondary/Supplemental Insurance Information

    Secondary/Supplemental Insurance Company Name
    Secondary/Supplemental Insurance Member ID Number
    Secondary/Supplemental Insurance Group Number
    Is the patient the subscriber (policyholder) of the Secondary/Supplemental Insurance? YesNo
    Secondary/Supplemental Insurance Subscriber Name

    First
    M.I.
    Last
    Subscriber Date of Birth
    Relationship to Patient
    Does the subscriber live at the same address as the patient? YesNo
    Please provide the subscriber's mailing address.
    Street Address
    Address Line 2
    City
    State
    ZIP

    Please enter the subscriber's mailing address.

    :


    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 2MB).

    Primary Card Front:

    Primary Card Back:


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

    Secondary Card Front:

    Secondary Card Back:


    The data submitted on this page will be captured by Accurate Medical Billing, Inc. (AMB), a company contracted by the Provider. This information can be used for the verification of eligibility and benefits. If a verification is performed by AMB, it 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 (AMB) has a signed a confidentiality agreement with the Provider. Any data collected with this submission will not be shared with any other entity besides the Provider. A copy of the confidentiality policy of the Provider and/or AMB is available upon request.