Step 1. Contact Information This form is confidential and HIPAA compliant First Name Last Name Phone Number E-mail Go back Next What type of billing question do you have? New Insurance Secondary Insurance Account Inquiries, Recent Charges or any other Billing Concerns Previous Next Primary Health Insurance Information Insurance Company Select Company Company A Company B ID Number Group ID Number Primary Insured Name Date of birth Social Security Number Relationship to the primary subscriber Insurance Plan Type PPO HMO EPO POS IPA Upload insurance front and back size Attach a copy of the front size of your primary insurance ID card Upload image Choose a photo or drag it here Attach a copy of the back size of your primary insurance ID card Upload image Choose a photo or drag it here Attach a copy of the front of your government-issued photo ID Upload image Choose a photo or drag it here I agree to New U Therapy Center & Family Services Terms of Use Previous Submit request Primary Health Insurance Information Insurance Company Select Company Company A Company B ID Number Group ID Number Primary Insured Name Date of birth Social Security Number Relationship to the primary subscriber Insurance Plan Type PPO HMO EPO POS IPA Upload insurance front and back size Attach a copy of the front size of your primary insurance ID card Upload image Choose a photo or drag it here Attach a copy of the back size of your primary insurance ID card Upload image Choose a photo or drag it here Attach a copy of the front of your government-issued photo ID Upload image Choose a photo or drag it here I agree to New U Therapy Center & Family Services Terms of Use Previous Submit request Please indicate your concern Previous Submit request
