Allscripts Insurance Master File

Allscripts Insurance Master File
Complete this request form when a new insurance must be added to the system. All information is required unless otherwise noted and must be complete for this request to be honored. This form can also be used to request a change to an existing record by noting the information that is to be revised.
Patient #:
Card scan or image available:
Insurance Company Name:
Insurance Category
(Available) ATTY BCBS CAID CARE COMM EAP HMO IME LIAB MALT MVA NH POS PPO SELF SPEC STAT TRVL WCOM ZDEF
Insurance Plan:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Insurance Phone - Primary:

Area CodePhone Number
Submitted By:

First NameLast Name
Insurance Phone - Additional:

Area CodePhone Number
Insurance Fax:

Area CodePhone Number
Special Instructions:
Date:

MonthDayYear
Phone Number:

Area CodePhone Number
Fax:

Area CodePhone Number
E-mail:
Internal Use
Status:
Status Details:
Completed By:

First NameLast Name
Date:

MonthDayYear
INS Code:
CAT Code:
PLAN Code:
Adj Code:
Pay Code:
Vision Use Only
Vendor Notified
Should be Empty: