Insurance Update | Northern Ohio Health and Wellness

Please update your insurance information.

If you have any questions don’t hesitate to call us at 216-440-2936.

Update Your Insurance Information

Name

First Last

Preferred Name

Phone

Name of Therapist

Address

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

Date of Birth

PLEASE UPLOAD THE FRONT AND BACK OF YOUR DRIVER'S LICENSE

Drop files here or

Max. file size: 256 MB.

PLEASE UPLOAD FRONT AND BACK OF YOUR INSURANCE CARD

Drop files here or

Max. file size: 256 MB.

Name of Insurance Holder

Address of Insurance Holder

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

Date of Birth of Insurance Holder

Is the Insurance Holder Male or Female?

Relationship of insurance holder to client? (Self, Child, Spouse, etc..).

Do you have secondary/supplemental insurance?

Yes

No

If Yes, please enter secondary/supplemental insurance information.

Enter Insurance Company, Group Number, ID Number

Who is the policy holder for your secondary/supplemental insurance?

Self

Relative

If relative please enter policy holder's first and last name.

Enter Insurance Company, Group Number, ID Number

If relative please enter date of birth of policy holder.

Enter Insurance Company, Group Number, ID Number

If relative, please enter address of policy holder.

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

Any additional information about our insurance change?