core4therapy_Annual

Annual Update
Is there a change to your information on file?

YesNo
Demographic Updates
Street Address
Apt./Unit #
City
State
Zip Code
Mobile Phone
Home Phone
Work Phone
Email address
example@example.com
Insurance Updates
I understand that it’s my responsibility to update my insurance and credit card information as changes occur or I will be responsible for any charges incurred as the result of my failure to supply new information, sign here:
Signature

Clear
1. Primary Insurance
Policy Number
Group Number
Secondary Insurance
Policy Number
Group Number
Other Insurance
Policy Number
Group Number
** IMPORTANT TO NOTE:

Please see the Core4 portal link at the end of this form to add insurance card photos, front and back, of each insurance card above.
Financial Updates
Do you have an updated Credit Card or FSA card you would like to update:

YesNo
Please provide updates below or call to update at 859-225-5424
1st 8 digits of card
last 8 digits of card
Expiration
CVV
Statement of Agreement
Please read statement here

If you have read and agree with the updated statement of agreement, sign here:
Signature

Clear
HIPAA
Please reach HIPAA statement here

If you have read and received a copy of your HIPAA rights, sign here.:
Signature

Clear
I agree that all information provided is accurate to the best of my knowledge.
Date

MonthDayYear
Date
Patient or Guardian Signature

Clear
Printed Name of Patient or Guardian:
PLEASE ENSURE THAT YOU UPLOAD YOUR INSURANCE CARD PHOTOS, FRONT AND BACK FOR EACH INSURANCE CARD LISTED ABOVE BEFORE HITTING SUBMIT.

CLICK HERE

DO NOT CLOSE THIS WINDOW. ONCE THE PHOTOS HAVE BEEN UPLAODED, PLEASE COME BACK TO THIS WINDOW AND HIT SUBMIT.
Should be Empty:

Annual Update

Demographic Updates

Insurance Updates

1. Primary Insurance

Secondary Insurance

Other Insurance

Financial Updates

Statement of Agreement

HIPAA