Great Lakes Psychology Group: Client Portal
Update or Submit Insurance Information
*You do not need to fill out this form if you gave us your insurance information over the phone or in a secure online chat when scheduling your appointment. Use this form if you did not have your insurance information available when you scheduled, if your insurance plan has changed, or if you need to submit secondary insurance information.
Patient Name
*
First
Last
Phone
*
Email
*
Can we contact you by Email?
*
Yes
No
Insurance Provider
*
Blue Cross PPO
BCN
HAP
Aetna / Cofinity
Cigna
Medicare
Medicaid
Private Pay
Other (Please Specify)
Other Insurance
*
Insurance Company Phone Number
*
Policy ID / Enrollee ID
*
Policy Group Number
Relationship to Insured
*
Self
Spouse
Child
Name of Insured (If other than self)
*
Insured Date of Birth
*
Patient Date of Birth
*
May we send you promotional emails and updates?
Yes
Phone
This field is for validation purposes and should be left unchanged.
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