Annual Client Insurance Update

Family Service Rochester is in the process of updating our client records. Insurance requires that we have a current signature & updated insurance information on file, on an annual basis. Please bring to your next scheduled appointment or fill out the form below along with a copy of your insurance card. If you would like to send your insurance cards electronically instead please provide your email below and mark yes to sending your insurance cards electronically, we will then send you an email with a link to send your cards through our secure portal. Thank you. 

Insurance requires that we have a current signature & updated insurance information on file, on an annual basis. Please complete the form below. A current copy of your insurance card is also required to continue services. Please bring to your next appointment or if you would like to send via secure SMS text, instructions follow this form.
Client Name :
Client Date Of Birth :
Address :
Apt/Suite #:
City:
State/Province:
Zip/Postal Code:
Phone :
Email :

Insurance Information

Primary Insurance Information
Fill in the following with the information of the client or guardian that holds the insurance
Type of Coverage:
Subscriber Name:
Date Of Birth :
Relationship to Client:
Phone Number:
Email Address:
Address:
Apt/Suite#:
City:
State:
ZIP:
Fill in the following with the institution providing the insurance’s information
Policy Number #:
Group Number #:
Fill in the following with the institution providing the insurance’s information
Insurance Company Name :
Address:
Suite#:
City:
State:
ZIP:
Phone Number:
Fax Number (optional):

Secondary Insurance Information
Fill in the following with the information of the client or guardian that holds the insurance
Type of Coverage:
Subscriber Name:
Date Of Birth:
Radio:
Phone Number:
Email Address:
Address:
Apt/Suite#:
City:
State:
ZIP:
Fill in the following with the institution providing the insurance’s information
Policy Number #:
Group Number #:
Insurance Company Name:
Address:
Suite#:
City:
State:
ZIP:
Phone Number:
Fax Number (optional):

A current copy of your Provider/ Insurance card will also be required for services. This generally is provided to you at the beginning of the calendar year. Please bring with a copy of your insurance card to your next scheduled appointment.
Texting Your Insurance Card Information:
A secure text option is available to send a photo of the front and back of your insurance card from your mobile phone.
1.- To start the process, Text to 779-999-3468.
2.- When sending the initial text, you will receive a confirmation text reply stating that “messages are responded to within 24 Hours M-F”.
3.-Upon receiving this text Family Service Rochester will reply with a consent message to authorize the exchange of PHI (Protected Health Information) via SMS text message.
4.-After you agree to consent, attach a photo copy of the front and back of your Insurance card.
You are under no obligation to authorize the exchange of PHI over SMS text message and that if you choose to authorize your PHI to be sent, you may opt-out at any time by calling 507-287-2010.
As a courtesy, our office bills your insurance company; however it is the sole responsibility of the patient to ensure that the bill is paid. We appreciate our clients’ support for prompt resolution of their accounts and will gladly assist in any effort to assure this.
Please call 507-287-2010 if you need more detail or instruction.

Insurance Billing and Payment Procedure
As a courtesy, our office bills your insurance company; however, it is the sole responsibility of the patient to ensure that the bill is paid. We appreciate our clients’ support for prompt resolution of their accounts and will gladly assist in any effort to assure this.

I authorize release to the above named insurance companies, third party payer or Medical Assistance, any information necessary to process this claim. I authorize payment of benefits under the terms of my policy/third party payer to be made directly to Family Service Rochester. I understand if insurance or any other third party payer does not cover these charges, I can be held financially responsible for payments for all services rendered for the above named client.
Signature Of Person Insured:
Date:

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