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1199 Benefits Fund
Aetna
Alicare
Allied Trades
Amerihealth
Amerihealth Administrators/Health Now
Beacon Health Options
Beacon of NY
Blue Cross Blue Shield
Carefirst
Carpenters Health and Welfare Fund of NJ
Cigna
Compsych
Concern & Concern Plus
Connecticare
Core Source
Covenant Health
Federal PPO (R Prefix)
GEHA
Geisinger – Unless Through Magellan
Geisinger Health Network
GHI
GHI Emblem Health
Guardian Health
Health Partners
Horizon Blue Cross Blue Shield of NJ
Humana
IE Schaeffer
Independence Blue Cross Blue Shield Personal Choice
Integrity Health
Kaiser
Keystone Health Plan East
Lehigh Valley Health Network
Magellan Health
Magna Care
Mental Health Network
Meritain
MHC (Mental Health Consultants)
MHN Managed Health Network
Multiplan
MVP
NY H&M Trades Council
Out of State Blue Cross Blue Shield
Penn Behavioral Health
Qualcare/ Health Republic
Spectrum Administrators
Total Care Network
Tritstate Health and Welfare Fund
UFCW / United Food and Commercial Workers / Health & Welfare Fund
United Behavioral Health
United Healthcare
University Healthcare
UPMC Health Plan
VA Community Care

PATIENT HEALTH INSURANCE
Patient's Name:
Full name of person seeking treatment
Patient DOB:
MM slash DD slash YYYY
Patient Address:
Patient City of Residence:
Patient State of Residence:
Patient Zip of Residence:
Insurance Name:
ID #:
Group #:
Please list ALL Telephone/800 #'s on your insurance ID card:
HEALTH INSURANCE INFORMATION (Patient is the Scubscriber)
Please note, your employer will not be notified. This information is held confidential by law.
Employer Name:
Employer Phone/Contact:
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Address:
This field is hidden when viewing the form
City:
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County and State:
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Zip:
Occupation:
How many years/months at present employer?:
IF APPLICABLE, SECONDARY INSURANCE -
Select subscriber relationship to patient
Name of subscriber:
DOB:*
SS#:
Employer (name, address, and phone):
OTHER HEALTH INSURANCE
Insurance Name:
ID #:
Group #:
Please list ALL Telephone/800 #'s on your insurance ID card:
Any comments/questions from person completing this form:
Follow-Up Contact Information
Name of person completing this form:
First Last
Contact Phone Number of person completing this form:*
Email address of person completing this form:*
How did you hear about us?*
Please tell us how you heard about us:*
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Name
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Verify Insurance

For Accepted Insurances Click Here

1199 Benefits Fund

Aetna

Alicare

Allied Trades

Amerihealth

Amerihealth Administrators/Health Now

Beacon Health Options

Beacon of NY

Blue Cross Blue Shield

Carefirst

Carpenters Health and Welfare Fund of NJ

Cigna

Compsych

Concern & Concern Plus

Connecticare

Core Source

Covenant Health

Federal PPO (R Prefix)

GEHA

Geisinger – Unless Through Magellan

Geisinger Health Network

GHI

GHI Emblem Health

Guardian Health

Health Partners

Horizon Blue Cross Blue Shield of NJ

Humana

IE Schaeffer

Independence Blue Cross Blue Shield Personal Choice

Integrity Health

Kaiser

Keystone Health Plan East

Lehigh Valley Health Network

Magellan Health

Magna Care

Mental Health Network

Meritain

MHC (Mental Health Consultants)

MHN Managed Health Network

Multiplan

MVP

NY H&M Trades Council

Out of State Blue Cross Blue Shield

Penn Behavioral Health

Qualcare/ Health Republic

Spectrum Administrators

Total Care Network

Tritstate Health and Welfare Fund

UFCW / United Food and Commercial Workers / Health & Welfare Fund

United Behavioral Health

United Healthcare

University Healthcare

UPMC Health Plan

VA Community Care

RESOURCES

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