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 5MB).

    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 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.

    Please click only once.