Update Insurance Information

"*" indicates required fields

Need to get insurance information to us? Please provide the details below.

In the event your insurance coverage changes, you need to notify us immediately. Not all services are covered benefits in all contracts. Some insurance companies select certain procedures or diagnoses that they will not cover. Knowingly giving false insurance information can result in insurance fraud.

Contact Phone Number:*

If there are questions about the information submitted, we will call to follow up. Please provide the telephone number that we can best reach you.

Client Information

Please submit siblings seperately

Client's Legal First Name*

Client's Legal Last Name*

Client's Date of Birth*

Insurance Cards

Attach a copy of each insurance card, including both the front and back:

Drop files here or

Accepted file types: jpg, gif, pdf, , Max. file size: 512 MB.

Insurance Type(s)

Insurance Type (select all that apply):*

No Insurance, will be self pay

Commercial Insurance

Medicaid (Forward Health)

ID Number:

Effective Date:

Commercial Insurance

Commercial Health Insurance Company Name:

Member ID Number:

Group Number:

Effective Date:

Subscriber's Full Name:

Subscriber's Date of Birth:

Subscriber's Gender:

Subscriber's Relationship to Patient:

Subscriber's Employer:

Subscriber's Address:

Street Address Mailing Address (if different than street address) City State ZIP Code

Additional Commercial Insurance

Is the patient covered under a secondary commercial insurance?*

Yes

Commercial Health Insurance Company Name:

Member ID Number:

Group Number:

Effective Date:

Subscriber's Full Name:

Subscriber's Gender:

Subscriber's Date of Birth:

Subscriber's Relationship to Patient:

Subscriber's Employer:

Subscriber's Address

Street Address Mailing Address (if different than street address) City State ZIP Code

If more than one insurance, which is primary and secondary?

Employee Assistance Program (EAP)

Please contact our Insurance Verification Team at 920-750-7075 to if you have an Employee Assistance Program (EAP) authorization that should be applied. Please note that once the EAP authorization has expired, Catalpa will bill the insurances on file. It is your responsibility to notify Catalpa Health of insurance coverages and/or additional authorizations. If we do not have insurance information, or if there is no active insurance, all future visits will be billed as Self-Pay.

Hidden

Do you have an Employee Assistance Program (EAP) Authorization?

Hidden

EAP Authorization Number:

Hidden

EAP Effective Date:

Hidden

Number of visits covered by EAP authorization:

Hidden

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Update Insurance Information

Client Information

Insurance Cards

Insurance Type(s)

Medicaid (Forward Health)

Commercial Insurance

Additional Commercial Insurance

Employee Assistance Program (EAP)

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