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SJ Health Insurance Advocates
2022-12-01T16:44:07+00:00
What facility is patient attending?
(Required)
Patient Information
Patient's legal name
(Required)
First
Last
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
(Required)
Email
(Required)
Patient's date of birth
(Required)
MM slash DD slash YYYY
Patient's member ID number
(Required)
Patient's group #
(Required)
Insurance Information
Do you have coverage with any of the below carriers?
(Required)
No
United Health Care (UHC)
Oxford
Optum
Harvard Pilgrim
Since your plan is administered by United Health Care (UHC), Oxford, Optum, or Harvard Pilgrim, you must call your insurance carrier to give permission for SJ Health Insurance Advocates to obtain benefits information. We will need the name of the person the requestor spoke with AND the reference number for the call.
Please provide the reference number and the person's name/phone number who you spoke to at the carrier.
(Required)
Insurance company contact information
Name of insurance carrier
(Required)
Insurance plan type
(Required)
HMO
EPO
PPO
POS
Unknown
Insurance Provider phone number (from insurance card)
(Required)
Insurance Behavioral Health phone number (from insurance card)
Subscriber's name
(Required)
First
Last
Subscriber's date of birth
(Required)
MM slash DD slash YYYY
Is subscriber's address different than the patient's address?
(Required)
Yes
No
Subscriber's address on file with insurance carrier
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
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