Patient Authentication
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Authentication Code
*
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Contact Info
Phone Number
*
Email Address
*
Patient Demographics
First Name
*
Middle Initial
Last Name
*
Date Of Birth
*
Gender
*
--- Select ---
Female
Male
Social Security Number
Address
Address 1
*
Address 2
City
*
State
*
--- Select ---
AL - Alabama
AK - Alaska
AZ - Arizona
AR - Arkansas
CA - California
CO - Colorado
CT - Connecticut
DE - Delaware
DC - District Of Columbia
FL - Florida
GA - Georgia
HI - Hawaii
ID - Idaho
IL - Illinois
IN - Indiana
IA - Iowa
KS - Kansas
KY - Kentucky
LA - Louisiana
ME - Maine
MD - Maryland
MA - Massachusetts
MI - Michigan
MN - Minnesota
MS - Mississippi
MO - Missouri
MT - Montana
NE - Nebraska
NV - Nevada
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NY - New York
NC - North Carolina
ND - North Dakota
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VT - Vermont
VA - Virginia
WA - Washington
WV - West Virginia
WI - Wisconsin
WY - Wyoming
Zip code
*
Employment
Place of employment associated with this policy
Existing Policies
Insurance Type
Coverage Level
Insurance Company
Insurance ID / Claim #
Providers Phone Number
Accident Date
Effective Date
Term Date
Relationship
to Policy Owner
New Policy Details
Insurance Type
*
--- Select ---
Medical Insurance
Veterans Insurance
Worker's Comp
Auto Accident Insurance
Insurance Company Name
*
Insurance Phone Number
Patient Insurance ID
*
Authorization Number
*
CCCN Network
ICN number
Allowed Number of Visits
Required Diagnosis Code
Patient’s Relationship to Policy Holder
*
Self
Spouse
Child
Other
Claim Number
*
Claim Adjuster First Name
Claim Adjuster Last Name
Claim Adjuster Phone Number
*
Date of Accident
*
State of Accident
*
--- Select ---
AL - Alabama
AK - Alaska
AZ - Arizona
AR - Arkansas
CA - California
CO - Colorado
CT - Connecticut
DE - Delaware
DC - District Of Columbia
FL - Florida
GA - Georgia
HI - Hawaii
ID - Idaho
IL - Illinois
IN - Indiana
IA - Iowa
KS - Kansas
KY - Kentucky
LA - Louisiana
ME - Maine
MD - Maryland
MA - Massachusetts
MI - Michigan
MN - Minnesota
MS - Mississippi
MO - Missouri
MT - Montana
NE - Nebraska
NV - Nevada
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NY - New York
NC - North Carolina
ND - North Dakota
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VT - Vermont
VA - Virginia
WA - Washington
WV - West Virginia
WI - Wisconsin
WY - Wyoming
Policy/Claim Number
*
Case Worker First Name
Case Worker Last Name
Case Worker Phone Number
*
Condition to be Treated
Primary Policy / Policy Holder’s Information
First Name
*
Middle Initial
Last Name
*
Date of Birth
*
Gender
*
--- Select ---
Female
Male
Policy Holder’s Address
Same as patient's
Address 1
*
Address 2
City
*
State
*
--- Select ---
AL - Alabama
AK - Alaska
AZ - Arizona
AR - Arkansas
CA - California
CO - Colorado
CT - Connecticut
DE - Delaware
DC - District Of Columbia
FL - Florida
GA - Georgia
HI - Hawaii
ID - Idaho
IL - Illinois
IN - Indiana
IA - Iowa
KS - Kansas
KY - Kentucky
LA - Louisiana
ME - Maine
MD - Maryland
MA - Massachusetts
MI - Michigan
MN - Minnesota
MS - Mississippi
MO - Missouri
MT - Montana
NE - Nebraska
NV - Nevada
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NY - New York
NC - North Carolina
ND - North Dakota
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VT - Vermont
VA - Virginia
WA - Washington
WV - West Virginia
WI - Wisconsin
WY - Wyoming
Zip Code
*
*
Required Field