VOB

Thank you for your interest in working with SJ Health Insurance Advocates. Please complete the form below and one of our team members will contact you right away. We look forward to working with you!

VOBadam2022-12-01T16:44:07+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 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)

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)

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

Subscriber's address on file with insurance carrier(Required)

Street Address Address Line 2 City State ZIP Code

Let’s Have A Conversation

30B Vreeland Road #301

Florham Park, NJ 07932

(973) 740-0023

SJ Health Insurance Advocates is the leader in behavioral health claims management.

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