Insurance Verification Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone *Date of Birth *required for insurance purposes Insurance Provider *InsuranceAetnaAllied Benefit Systems-AetnaAllSavers UHCChristian Brothers Services-AetnaCigna (Florida ONLY)Health Plans Inc.Health Scope-AetnaMeritainNipponOscarOxford Health PlansSurest (formerly Bind)Trustmark Health Benefits-AetnaTrustmark Health Benefits-Cigna (Florida ONLY)UHC Student ResourcesUMRUnited Healthcare Shared ServicesUnitedHealthcareUnitedHealthcare GlobalMember ID *Group Number *Address Associated with Insurance *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSex *MaleFemale'Sex' is a required field on the insurance claims form. Are you the primary subscriber? *YesNoPrimary Subscriber's Name *FirstLastSubscribers Date of Birth *Sex of Primary Subscriber *MaleFemale'Sex' is a required field on the insurance claims form. Relationship *Select Relationship OptionParentGuardianSpouseDomestic PartnerUpload Front of Insurance Card * Click or drag a file to this area to upload. Upload Back of Insurance Card * Click or drag a file to this area to upload. Submit
