CARY ADULT MEDICINE - Publicforms

Available Forms

Back Pain E-Visit Billing Question Blood Pressure Log Blood Sugar Readings Cold/Flu/Sinus/Cough//Throat/Respiratory Infection Comments or Suggestions Conjunctivitis/Pink Eye Depression Screening (PHQ9) Flu Shot Health Care Question HIPPA Hospitalization Insurance Change Form Lab Result Follow-up Question Living Will/Health Power of Attorney Medical History/Preventative Update Medicare Wellness Exam New Patient Medical History New Patient Registration Form Password - Patient Request for Secure Password Patient Education Classes Prescription Refill Request Preventative Care Referral Question Specialist/ER/Hospital/Testing Update Specialist/Urgent Care or Hospital Visits Survey- Cary Adult Medicine Telemed Urinary Tract Infection Voluntary Alignment for Medicare ACO REACH Yeast Infection

Insurance Change Form

If your insurance has changed since your last visit please complete this form. If possible send a scanned copy of your card through the secure patient portal. If you do not have your password complete the password request form

Your Name *

Your Date of Birth *

Subscriber Name

If you are the subscriber please enter your name. If the subscriber is your spouse or parent please put their name as it appears on the insurance card

Subscriber ID

Group Number

Date Issued

If applicable

Co-pay

Enter the amount of the copay or member responsibility for primary care. If not available leave blank

Street address to mail medical claims

Usually on back of card. If not available leave blank or if says mail to local carrier then check the box in the following question

City, State, Zip code to mail medical claims

Usually on back of card. If this says to mail to local carrier or office please check the box in the next question

Mail to local insurance Carrier

Many out-of-state Blue Cross and some other insurance companies require that claims be mailed to the local company. Please check this box if your card instructs local billing of claims

Other Information

Please add any other information you feel is relevant

* Required field