New Patient Portal - Accurate Medical Billing

Name of Provider

Provider

Search by provider name, practice name, or city.

Patient's Name

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

First Middle Last

Mailing Address

Address

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

Contact Email Address

Phone Contacts

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

Primary Phone

Primary Phone Type

Alternate Phone 1

Alternate Phone 1 Type

Alternate Phone 2

Alternate Phone 2 Type

Patient's Date of Birth

Date of Birth

Patient's Gender

Patient's gender as recognized by the insurance company.

Female

Male

Insurance Information

Hidden

Insurance Information

Primary Insurance Company Name

Member ID Number

Group Number

Is the patient the subscriber (policyholder)?

Yes

Hidden

Subscriber / Policyholder Info

Subscriber Name

First Middle Last

Subscriber Date of Birth

Relationship to Patient

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

Yes

Please provide the subscriber's mailing address.

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

Hidden

Secondary Insurance

Does the patient have a secondary/supplemental insurance policy?

Yes

Secondary / Supplemental Insurance Information

Hidden

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?

Yes

Hidden

Secondary/Supplemental Insurance Subscriber Info

Secondary Insurance Subscriber Name

First Middle Last

Secondary Insurance Subscriber's Date of Birth

Secondary Insurance Subscriber's Relationship to Patient

Does the Secondary Insurance Subscriber live at the same address as the patient?

Yes

Please provide the Secondary Insurance Subscriber's mailing address.

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

Hidden

Insurance ID Card

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

Drop files here or

Accepted file types: pdf, png, gif, jpg, jpeg, Max. file size: 5 MB, Max. files: 1.

Primary Card Back

Drop files here or

Accepted file types: pdf, png, gif, jpg, jpeg, Max. file size: 5 MB, Max. files: 1.

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

Yes

Secondary Card Front

Drop files here or

Accepted file types: pdf, png, gif, jpg, jpeg, Max. file size: 5 MB, Max. files: 1.

Secondary Card Back

Drop files here or

Accepted file types: pdf, png, gif, jpg, jpeg, Max. file size: 5 MB, Max. files: 1.

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.

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.

Phone

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