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 3MB).

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.