New Patient Portal TEST "*" indicates required fields Name of ProviderProviderSearch by provider name, practice name, or city.Start typing...Acevedo, Jane, LCSW - Jane Acevedo, LCSW - Santa Fe, NMAdams, Reina, LMFT - Catholic Charities Hawaii - Honolulu, HIAlexander, Bertha, TLPC - Serenity Counseling & Mediation Center - Gallatin, TNAlvarez, Terri, LCSW - Terri Alvarez, LCSW - Las Cruces, NMAmes, Gary, MA - Gary Ames, Licensed Psychologist - Bala Cynwyd, PAAnderson, Aaron, LMFT - Parker Counseling Services LLC - Parker, COArloo, Johnson, LPC - Behavioral and Substance Abuse Counseling - Madison, ALAsllani, Ardita, MMFT - Serenity Counseling & Mediation Center - Gallatin, TNAtkins, Abigail, Ed.D. - Abigail Atkins Ed.D. - Phoenix, AZAune, Cynthia, LCSW - Cynthia H Aune, LCSW - Sandy, UTBader, Christin, LMFT - Christin Bader, LMFT - Rocklin, CABaird, Amy, LCPC - Restored Counseling Inc. - Peoria, ILBaird, Scott, LCPC - Restored Counseling Inc. - Peoria, ILBarger, Meredith, LCPC - Inspirit Counseling Services, Inc. - Columbia, MDBashawaty, Karen, MA, LLP, LPC - KAB Counseling, PLLC - Clarkston, MIBeatty, Darlene, LCSW - Catholic Charities Hawaii - Honolulu, HIBeaulieu, Christie, LMSW - Greater New Haven Cnsling & Therapy Ctr - Hamden, CTBekker, Aida, LCSW - Riverview Psychological Services PC - Fishkill, NYBerardo, Doris, LCSW - Riverview Psychological Services PC - Fishkill, NYBirenbaum, Susan, LCSW - Susan Birenbaum, LCSW, MBA, C-ASWCM - New York, NYBogart, Solomon, LCPA - Greater New Haven Cnsling & Therapy Ctr - Hamden, CTBoyd, Lavon, LCSW - Lavon T Boyd, LCSW - Lees Summit, MOBoyer, Jeffrey, LMSW - Psychotherapy & Counseling Services PC - Northville, MIBradshaw, Thomas, LCSW - Inspirit Counseling Services, Inc. - Frederick, MDBrieger, Julie, Ph.D., LPC - Wellspring of Life, LLC - Erie, PABrinkman, Christene, LPC-S, LCDC - Creative Counseling - Richardson, TXBruinooge, Erica, LSW - Parker Counseling Services LLC - Parker, COBurks, Daniel, LMFT - Juliann R Burks, LMFT, PLLC - Johnson City, TNBurks, Juliann, LMFT - Juliann R Burks, LMFT, PLLC - Johnson City, TNButler, Deborah, LPC - Deborah Butler, LPC - Johnson City, TNButler, Tracey, LCPC - Tracey Butler Counseling & Consulting Inc - Gathersburg, MDByrnes, Laura, LCSW - Kids On Up Psychotherapy, Inc. - Chapel Hill, NCCain, Juliet, LCSW - Inspirit Counseling Services, Inc. - Baltimore, MDCambron-Adams, Connie, LCSW - Cambron Talbott Counseling - Peoria, ILCamilierri, Regina, LMFT - Treehouse Wisdom and Wellness, Inc. - Cortlandt Manor, NYCampagna, Anthony, Ph.D. - Greater New Haven Cnsling & Therapy Ctr - Hamden, CTCampos, Luiza, MFT - Treehouse Wisdom and Wellness, Inc. - Cortlandt Manor, NYCarey, Mark, LPC - Kansas City Trauma and Wellness, LLC - Kansas City, MOChandross, Wendy, LCSW - Wendy Chandross, CISW, PC - Glendale, AZChavez, DonnaLee, LMFT - Greater New Haven Cnsling & Therapy Ctr - Hamden, CTChurchill, Chiyo, LMFT - Catholic Charities Hawaii - Honolulu, HICleary, Jackie, LPC, LMFT - Cleary Counseling and Consultation, Inc. - Tulsa, OKCoates, Kelly, LPC - Kelly Coates, LPC - Erie, PACohn, Susan , LCSW - Susan Cohn, LCSW - Ardsley, NYCongdon, Diana, APRN - Greater New Haven Cnsling & Therapy Ctr - Hamden, CTConner, Karen, LCSW - Inspirit Counseling Services, Inc. - Cockeysville, MDCordova, Michal, LCSW - Catholic Charities Hawaii - Honolulu, HICramer, Gill (Terry), LCSW - Cramercare - Brooklyn, NYD'Andrea, Alisa, LMFTA - Greater New Haven Cnsling & Therapy Ctr - Hamden, CTDamond, April, LPC - Wellspring of Life, LLC - Erie, PADamond, Patrick, LPC - Wellspring of Life, LLC - Erie, PADeCesare, Patrese, LCSW - Patricia DeCesare, LLC - Gathersburg, MDDeCesare, Patrese, LCSW - Patricia DeCesare, LLC - Gathersburg, MDDiLorenzo-Gomez, Kayla, LCSW - Riverview Psychological Services PC - Fishkill, NYDiMarzio, Cate, LCPC - Cate DiMarzio LLC PC - Yarmouth, MEDougherty, Kevin, LCSW - Kevin Dougherty Counseling - Denver, CODuCote, Sonte, LCSW - Inspirit Counseling Services, Inc. - Baltimore, MDDunson, Courtney, LPCC - Parker Counseling Services LLC - Parker, CODwyer, John, Psy.D. - The Meridian Group of Chesterfield, LLC - Chesterfield, VAEckerberg, Helena, Ph.D. - San Diego Psychotherapy Associates - San Diego, CAEpstein, David, Psy.D. - David Epstein, Psy.D. - Richmond, VAEsposito, Benita, LPC - The Esposito Institute, Inc. - Blairsville, GAEstante, Maria Rheba, LICSW - Exposure Therapy Designs - Sacramento, CAEvans, Antoinette (Toni), MA, LMFT - Transformative Counseling and Family Services, LLC - Normandy Park, WAFarley, Lauren, LPC - Lauren C Farley, LPC - Media, PAFindlay, Melissa, LCSW - FamilyWork - Chesterfield, VAFleming, James, MD - Integrative Psychiatry - Kansas City, MOFleming, Teresa, LPC/MHSP - Teresa Fleming, LCP - Johnson City, TNFletcher, Ami - Serenity Counseling & Mediation Center - Gallatin, TNFowler, Heather, LPC - Before & After Counseling, LLC - Avis, PAFrederick, Julie, LCPC - The Empowerment Group LLC - Kalispell, MTFritz, Nathan, LMHC - Harmonious Friends Counseling, PLLC - Normandy Park, WAGallo, Kayla, LMSW - A Balanced Life, LLC - Kansas City, MOGannon, Laura, LMSW - Treehouse Wisdom and Wellness, Inc. - Cortlandt Manor, NYGarcez, Larissa, LCSW - Treehouse Wisdom and Wellness, Inc. - Cortlandt Manor, NYGarcia, Nicoletta, LCSW - A Balanced Life, LLC - Kansas City, MOGetter, Nancy, LCSW - Inspirit Counseling Services, Inc. - Cockeysville, MDGhany, Jamie, Ph.D. - Jamie Ghany, Ph.D. - Enfield, CTGiesey, Eve, LPC-MHSP - Grace Pointe Counseling Center - Johnson City, TNGifford-Smith, Mary, Ph.D. - Riverview Psychological Services PC - Fishkill, NYGlass, Lynessa, LMFT - Lynessa Glass, Inc. - Newport News, VAGoldwater, Shachar, LPCC - Parker Counseling Services LLC - Parker, COGrande, Caren, LCSW - Caren Grande, LCSW, LLC - Red Bank, NJGreene, Karen, LPC/LFMT - Crossings Counseling Center - Marietta, GAGrennan, Hillary, LCSW - Live Well Psychology Center, LLC - Sparta, NJGriffith, Peggy, LPC - Peggy Griffith, LPC - Jasper, GAGross, Jeffrey, Th.D., Ph.D., SAC-IT - Nicklaus Counseling Center - Marinette, WIGrosu, Victor, M.D. - Child Psych Services, LLC - Brick, NJHankins, Leroy, LCSW - Riverview Psychological Services PC - Fishkill, NYHanson, Jean, Ph.D. - Hanson Psychological Services LLC - Danvers, MAHanson, Mark, Ph.D. - Hanson Psychological Services LLC - Danvers, MAHarris, Natasha, LMSW - A Balanced Life, LLC - Kansas City, MOHarrison, Sheryl, Ph.D. - Sheryl W. Harrison, Ph.D., LLC - Scottsdale, AZHawthorne, Caro, LCSW-R - Caro Hawthorne, LCSW-R - New Windsor, NYHeater, Rachel, LMFT - Treehouse Wisdom and Wellness, Inc. - Cortlandt Manor, NYHeineken, Tawnya, LPCC - Heineken Counseling, LLC - Las Cruces, NMHemmert, Elizabeth, LICSW - Elizabeth's Counseling - Normandy Park, WAHilgenkamp, Katy, LCPC - Katy Hilgenkamp, LCPC - Lincoln, NEHimes, Sarah, MA, LMHC - Sarah Himes Counseling - Normandy Park, WAHoffe, Lindsay, MA, LMFT - Lindsay Hoffe Counseling, LLC - Normandy Park, WAHolzhauser, Breanna, MSW - Parker Counseling Services LLC - Parker, COHughes, Robert, Ph.D. HSP - NeuroBehavioral Associates, PLLC - Johnson City, TNJackson, Jill, LPC - Serenity Counseling & Mediation Center - Gallatin, TNJacobson, Robert, LCSW-C - Robert Jacobson, LCSW-C - Baltimore, MDJolivette, Michelle, MS, LPC, NCC - Jolivette Affirmative Counseling - Lafayette, LAJonak, Nicole, SLP - Speech & Language Connections - Vancouver, WAJones, Sharmain, LCSW - Greater New Haven Cnsling & Therapy Ctr - Hamden, CTKeenan, Elisabeth, MSW - Riverview Psychological Services PC - Fishkill, NYKelleher, Brenda, MSW, LCSW, LICSW - Brenda Kelleher, MSW, LCSW, LICSW - Topsham, MEKeller, Arnold, LMSW - Psychotherapy & Counseling Services PC - Northville, MIKeller, Heidi, Ph.D. - Live Well Psychology Center, LLC - Sparta, NJKiernan, Eliza, LPC-MHSP - J Eliza Kiernan, LPC-MHSP - Johnson City, TNKing, Shannon, MSW - Parker Counseling Services LLC - Parker, COKnox-Holub, Jodi, LCPC - Jodi Knox-Holub, LLC - Pekin, ILKobes, Solomon, LCSW - Kids On Up Psychotherapy, Inc. - Chapel Hill, NCKofender, Jill, Ph.D. - Jill L. Kofender Ph.D., PLLC - Waterford, MIKohl, Andrew, MA, NCC, LPC - Shaping Successful Futures Counseling LLC - Erie, PAKomm, Richard, Ed.D. - Phx Psychological Testing &Treatment - Phoenix, AZKorenblatt, Janice, LCSW - Janice Korenblatt, LCSW - Ardsley, NYKyle-Wolf, Lisa, LCSW - 7th Direction - Peoria, ILLang, Tim, Psy.D., ABPP - Southern Minnesota Psychological Services, PLLC - Albert Lea, MNLangley, Teresa (DeAnn), LPC-MHSP - Teresa DeAnn Langley, LPC, LLC - Buford, GALaRoche, Jennifer, LPC - Compass Behavioral Health - Erie, PALassen, Maureen, Ph.D. - Maureen K. Lassen, Ph.D., PC - Mesa, AZLawson, John, LMFT - John Lawson, LMFT - Johnson City, TNLilly, Shawn, LPC - Serenity Counseling & Mediation Center - Gallatin, TNLinsmeier, Taylor, LCSW - Greater New Haven Cnsling & Therapy Ctr - Hamden, CTLopez, Luz, MS - Greater New Haven Cnsling & Therapy Ctr - Hamden, CTLott Farmer, Lyndis, LMFT - Catholic Charities Hawaii - Hilo, HILove, Marissa, LPCC - Magnolia Counseling, LLC - Las Cruces, NMLudwig, Rosemarie, LPC/Ph.D. - Phoenix Psychological Services - Phoenix, AZLundgren, Susanne (Lily), LPC - Flying Heart Ranch, LLC - Phoenix, AZMagarian, Angela, LCSW - Angela Magarian Christian Counseling, LLC - Norman, OKMahon, Moira, MCCA - Greater New Haven Cnsling & Therapy Ctr - Hamden, CTMancuso, Michele, LCSW - TruCare Counseling Services, LLC - Tinton Falls, NJManela, Pamela, LMSW - Psychotherapy & Counseling Services PC - Northville, MIMason, Te'Asia, LPC - Behavioral and Substance Abuse Counseling - Madison, ALMcGaha, Colter, LPC - Clover Counseling LLC - Huntsville, ALMcGrath, Teresa, LPC/LFMT - Teresa L McGrath, LPC, LMFT - The Woodlands, TXMcKinley, Marcia, LCPC - Marcia J. McKinley JD, PhD, LCPC - Gathersburg, MDMcKinney, Jane, LCSW - A Balanced Life, LLC - Kansas City, MOMcLellan, Autumn, LPC - Autumn McLellan, LPC - Erie, PAMcManus, Sheila, Ph.D. - Dr. Sheila McManus, Ph.D. - Philadelphia, PAMcMurtry, Sarah, Psy.D. - Perspectives Psychological Resources, LLC - Atlanta, GAMetzendorf, Beth, LCSW - Beth Metzendorf, LCSW - Larchmont, NYMichalczyk, John, LCPC - Inspirit Counseling Services, Inc. - Westminster, MDMiers, Carol, LPC/LFMT - Carol S. Miers Inc. - Houston, TXMika, Ashley, LICSW - Enlightened Journey Counseling, LLC - Elkhorn, WIMiller, Alexandra, Psy.D. - Live Well Psychology Center, LLC - Sparta, NJMiller, Eleonora, LCSW - Greater New Haven Cnsling & Therapy Ctr - Hamden, CTMiller, Mary, Ph.D. - Psychotherapy & Counseling Services PC - Northville, MIMirkin, Lauren, LCPC, LDN - Lauren I Mirkin, LCPC, LDN - Lutherville, MDMount, David, Psy.D. - Mind Body Institute of the Piedmont PLLC - Winston-Salem, NCMullen, Debra, LCSW - Nicklaus Counseling Center - Marinette, WIMyers, Charlene, LPC - Heart and Soul Counseling and Consulting Services - Erie, PANakanishi, Amy, LMFT - Catholic Charities Hawaii - Hilo, HINicklaus, Christine, LPC - Nicklaus Counseling Center - Marinette, WINordenberg, Liora, LCPC - Inspirit Counseling Services, Inc. - Baltimore, MDNordin, Matthew, LICSW - Mindful Mountain Therapy, PLLC - Seattle, WANovak, Elizabeth, LCSW - Elizabeth A. Novak, LCSW - Chesterfield, VAOlivieri, Jamie, MFT - Treehouse Wisdom and Wellness, Inc. - Cortlandt Manor, NYPaine, Terry, LCSW - A Balanced Life, LLC - Kansas City, MOPal, Melee, Psy.D. - San Diego Psychotherapy Associates - San Diego, CAPatti, Sherry, LCSW - Sherry Patti, LLC - Plainfield, ILPavao, Maile, LCSW - Catholic Charities Hawaii - Hilo, HIPearson, Amber, LPC - Integrated Wellness and Strategies, LLC - Broomfield, COPeck, Lisa, LMHC - Catholic Charities Hawaii - Honolulu, HIPeck, Melissa, LPC - Wellspring of Life, LLC - Erie, PAPerlman, Greg, LCSW - Treehouse Wisdom and Wellness, Inc. - Cortlandt Manor, NYPinnell, Cornelia, Ph.D. - Cornelia Pinnell, Ph.D. - Glendale, AZPowell, John, Ph.D. - John Powell, Ph.D. - Rocklin, CAPowers, James, LLPC - Psychotherapy & Counseling Services PC - Northville, MIPowers, Joan, LMFT - Joan L. Powers, LMFT - Rocklin, CAPrymuszewski, Theresa, LCPC - Inspirit Counseling Services, Inc. - Linthicum Heights, MDRamos Gomez, Catalina, LCSWA - Kids On Up Psychotherapy, Inc. - Chapel Hill, NCRiggs, Catherine, LCSW - Tri-Cities Counseling Services, PLLC - Tazewell, VARiviello, Tom, LMHC - Tom Riviello Mental Health Counseling,PC - Sayville, NYRobbins-Thompson, Lane, LCSW - Kids On Up Psychotherapy, Inc. - Chapel Hill, NCRobbins, David, LPC - DP Robbins Psychology Resources LLC - Forsyth, MORobbins, Kelli, LCSW - Riverview Psychological Services PC - Fishkill, NYRomero, Rita, Ph.D. - San Diego Psychotherapy Associates - San Diego, CARoper, Bradley, LCSW - Brad Roper, LLC - Lovell, WYSalemme, Thomas, LCSW - Greater New Haven Cnsling & Therapy Ctr - Hamden, CTSales, Roslyn, LCP - Behavioral and Substance Abuse Counseling - Madison, ALSalvatore, Robert, LPC - Psychotherapy & Counseling Services PC - Northville, MISarma, Subbu, MD - Subbu J Sarma MD, LLC - Kansas City, MOSchellenberg, Paul, LCPC - Paul Schellenberg LLC - Peoria, ILSchulte, Rita, LPC - Rita A Schulte, LPC - Fairfax Station, VASchultz, Nikki, LCSW - Treehouse Wisdom and Wellness, Inc. - Cortlandt Manor, NYSeawell, JoAnne, LPC, LMFT - JoAnne Seawell LPC - Midlothian, VAServiss, Suzanne, LCSW - Greater New Haven Cnsling & Therapy Ctr - Hamden, CTSexton-Newton, Jill, LPC - The Meridian Group of Chesterfield, LLC - Chesterfield, VASiegel, Bobette, LCSW - Bobette Smith Siegel, MSW, LLC - Scottsdale, AZSilva, Scarlett, MSW - Parker Counseling Services LLC - Parker, COSimmons, Chelsi, LPC - The Meridian Group of Chesterfield, LLC - Chesterfield, VASlater, Bonnie, LPC - Bonnie Slater, LPC - Scottsdale, AZSmith, Amber, LPC - Amber N. Smith, LLC - Denver, COSmith, Daryl, LICSW, MHP - Balance of Mind Therapeutic Support - Austin, MNSmith, Janine, LPCC - New Pathways Counseling, LLC - Las Cruces, NMSmith, Peter, LCSW-C - Inspirit Counseling Services, Inc. - Baltimore, MDSolomon, Judith, Ph.D. - Greater New Haven Cnsling & Therapy Ctr - Hamden, CTSparrow, Nancy, LMSW - Nancy Sparrow, LMSW - Royal Oak, MIStanton, Stephanie, LMHC - Stephanie Stanton Therapy, PLLC - Normandy Park, WASteinborn, Sharon, LMFT - Anxiety Treatment Center of the SW, PC - Las Cruces, NMStringham, Halley, MFT - Treehouse Wisdom and Wellness, Inc. - Cortlandt Manor, NYStudham, Mary, LCSW-C - Inspirit Counseling Services, Inc. - Severna Park, MDSurval, Miriam, LCSW - Riverview Psychological Services PC - Fishkill, NYSutek, Ivy, CSAC, CADC - Nicklaus Counseling Center - Marinette, WISwartout, Ilyssa, Psy.D. - Growing Edges LLC - Glendale, AZTapia, Crystal, LCSW - Pure Clarity Counseling, LLC - Las Cruces, NMTawata, Dawn, LCSW - Catholic Charities Hawaii - Honolulu, HITerrazas, Joe, LPCC - Joe Terrazas Mental Health, Inc. - Las Cruces, NMTerron, Rochely, LPC/LMHC - HOPE Virtual Counseling & Therapy LLC - Homestead, FLTerry, Josette, MFT - Treehouse Wisdom and Wellness, Inc. - Cortlandt Manor, NYTrukositz, Mary, LMHC - Mary Trukositz, LMHC - Kennewick, WAVan Walleghem, Nicholas, LCSW - A Balanced Life, LLC - Kansas City, MOVanderwalde, Heidi, LPC - Heidi Vanderwalde, LCPC - Derwood, MDWalker, Kayla, LPC - Wellspring of Life, LLC - Erie, PAWalker, Unity, LPC - Behavioral and Substance Abuse Counseling - Madison, ALWathen, Megan, MSW - Parker Counseling Services LLC - Parker, COWebb-Tafoya, Mary, LPC - Mary Webb-Tafoya PLLC - Austin, TXWest-Effland, Sarah, LCSW - Sarah West-Effland LCSW, LLC - Lees Summit, MOWilliams, Cynthia, LPC - Psychotherapy & Counseling Services PC - Northville, MIWitkowski, Kim, LCPC - Inspirit Counseling Services, Inc. - Baltimore, MDWood, Deborah, LPC - Next Chapter Counseling LLC - Mechanicsville, VAWool, Brittany, LPC - Live Well Psychology Center, LLC - Sparta, NJWright-Aguilar, Elena, LCSW-C - Elena Wright-Aguilar, LCSW-C - Germantown, MDWynn, Cynthia, LMHC, CASAC - Treehouse Wisdom and Wellness, Inc. - Cortlandt Manor, NYZeiber, Andrea, LPC - Wellspring of Life, LLC - Erie, PAZweig, Lea, Psy.D. - San Diego Psychotherapy Associates - San Diego, CA Patient's NamePatient's NamePlease provide the patient's name exactly as it's printed on their health insurance card. 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Please enter with no spaces or special characters.Primary PhonePrimary Phone Type--Please choose an option--MobileHomeWork/OtherAlternate Phone 1Alternate Phone 1 Type--Please choose an option--MobileHomeWork/OtherAlternate Phone 2Alternate Phone 2 Type--Please choose an option--MobileHomeWork/Other Patient's Date of BirthDate of Birth Month Day Year Patient's GenderPatient's GenderPatient's gender as recognized by the insurance company. Female Male Insurance InformationHiddenInsurance InformationPrimary Insurance Company Name Member ID Number Group Number Is the patient the subscriber (policyholder)? Yes No HiddenSubscriber / Policyholder InfoSubscriber Name First Middle Last Subscriber Date of Birth Month Day Year Relationship to Patient-- Please choose --SpouseLife PartnerChildEmployerOtherDoes the subscriber live at the same address as the patient? Yes No Please provide the subscriber's mailing address. Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country HiddenSecondary Insurance Does the patient have a secondary/supplemental insurance policy? Yes No Secondary / Supplemental Insurance InformationHiddenSecondary / Supplemental Insurance InformationSecondary / 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 No HiddenSecondary/Supplemental Insurance Subscriber InfoSecondary Insurance Subscriber Name First Middle Last Secondary Insurance Subscriber's Date of Birth Month Day Year Secondary Insurance Subscriber's Relationship to Patient-- Please choose --SpouseLife PartnerChildEmployerOtherDoes the Secondary Insurance Subscriber live at the same address as the patient? Yes No Please provide the Secondary Insurance Subscriber's mailing address. Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country HiddenInsurance ID Card Insurance ID Card UploadPlease 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 Select files Accepted file types: pdf, png, gif, jpg, jpeg, Max. file size: 5 MB, Max. files: 1. Primary Card Back Drop files here or Select files 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 No Secondary Card Front Drop files here or Select files Accepted file types: pdf, png, gif, jpg, jpeg, Max. file size: 5 MB, Max. files: 1. Secondary Card Back Drop files here or Select files 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. 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.*Please click only once.EmailThis field is for validation purposes and should be left unchanged.