Insurance Check | Holistic Health Associates

This field is for validation purposes and should be left unchanged.

Which Location Will You Be Visiting?*

Frederick
Boonsboro

How Did You Hear About Us?*

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

we may need to reach you to verify information for the insurance company.

Email*

Date of Birth*

Insurance Company*

Insurance Member ID#*

Group #/ Enrollment Code*

Provider/ Member Services #*

Subscriber Name*

Subscriber Date of Birth*

Patient relationship to Subscriber*

Do you have secondary insurance?*

No
Yes

Secondary Insurance Co.*

For Secondary Insurance

Secondary Ins. Member ID*

For Secondary Insurance

Secondary Group #/Enrollment Code*

For Secondary Insurance

Secondary Provider/Member Services #*

For Secondary Insurance

Secondary Subscriber Name*

For Secondary Insurance

Secondary Subscriber Date of Birth*

For secondary Insurance

Are you on Medicare?

No
Yes

Medicare member #*

Is the reason you are coming related to a Workers Comp, Auto Accident or Personal Injury case?*

Yes
No

Our office does not process to your personal health insurance for Workers Comp, Auto Accident or Personal Injury related cases unless you provide a Letter of Subrogation from your insurance company or a PIP exhaust letter to our office. If you are unable to provide that to our office, you will be required to pay the self-pay rate at each appointment and we will not process your claim to your insurance. We can give you the appropriate supporting documents to seek reimbursement on your own. If you have any questions or would like to speak to someone further, please call our main number at 301-620-1414 and leave a voicemail with our Insurance Team or email insurance@hhamd.com.

Upload a Copy of your Insurance Card (Front)

Max. file size: 128 MB.

Upload a Copy of your Insurance Card (Back)

Max. file size: 128 MB.

How would you like us to contact you with the information we receive from your insurance company regarding your benefits and coverage?*

Email
Phone

I understand a quote is an estimation of coverage - Holistic Health Associates is just the messenger! It is not a guarantee that your insurance will pay your claims or that all quoted information is final. Your insurance policy is a contract between you/your employer and the insurance company - our office is not party to that contract.

Please keep in mind that the information relayed to you is a quote our office has received directly from your insurance company. It is designed as a courtesy to you, to help provide an estimation of what to expect from your coverage. Although it is rare, sometimes your final coverage determined during claims processing can differ from the information relayed originally. Please be aware that some and perhaps all of the services provided may be considered non-covered or denied under your plan based on the limitations in your policy. Any non-covered or denied services will become your full financial responsibility as outlined in our Financial Policy. Please read your Evidence of Coverage booklet that you received from your insurance company as to what types of services are not covered under your policy or contact your insurance company directly if you have specific questions about your coverage.

Free Insurance Benefits Check