Patient Insurance & Demographic Update Patient's Name:(Required) First Last Patient's Date of Birth:(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Parent/Guardian Name (if patient is a minor): First Last Email Address (Person Completing this Form):(Required) Phone - Best Contact Number (Person Completeing This Form):(Required)I Need to Update:(Required) Name Address Telephone Number(s) Email Address Insurance Coverage Updated Patient Name:(Required) First Last Updated Patient Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Updated Primary Phone:(Required)Updated Email Address:(Required) Enter Email Confirm Email Update to Insurance - Please upload a copy of the FRONT & BACK of your new insurance card or email to billing@indianahealthgroup.com(Required) Anthem Cigna ComPsych Midwest Behavioral Sagamore / IHN United Healthcare / United Behavioral I no longer have insurance coverage. Other Insurance - If your insurance company is not listed above, our office is not in network. We will be happy to file your claims for out of network consideration. Mental health benefits may be administered by a plan other than your primary healthcare benefits. We highly encourage each patient to familiarize themselves with their mental health benefits and confirm the participation status for the provider they wish to see. Patients are ultimately responsible for charges incurred as a result of services rendered with an out-of-network provider.Primary Insured Name: First Last Identification Number: Group Number: Insurance Phone Number:Claims Address: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Uploade Front & Back of Insurance Card: Drop files here or Select files Accepted file types: jpg, png, pdf, Max. file size: 128 MB.
