Insurance Information Patient Name First Last Insured Name First Last RelationshipNoneSpouseMotherFatherGuardianPower of AttorneyDate of Birth MM slash DD slash YYYY Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance Company NameAETNAAETNA – EAPANTHEMASAGEHACapital Blue CrossComPsychFEPHEALTH ADVOCATE SOLUTIONSHighmark Blue Cross & Blue Shield of PennsylvaniaIBHLifeSolutions EAPLyra EAPMagellanMedicareMAZZITTI & SULLIVANMORNEAU SHEPELLOptum Behavior HealthOPTUM – EAPOptumHealthQuest Behavior HealthSpringHealth EAPTricareUnitedHealthcareGroup Number Insurance ID Number (Optional) Copy of Insurance Card Drop files here or Select files Accepted file types: jpg, png, pdf, doc, Max. file size: 8 MB. EAP InformationEAP Name Authorization Number/Referral Number Number of Sessions Authorization Dates Name of employer group Name of employee Relationship Secondary InsuranceInsured Name First Last RelationshipNoneSpouseMotherFatherGuardianPower of AttorneyDate of Birth MM slash DD slash YYYY Insurance Company NameSelect Secondary InsuranceAETNAAETNA – EAPANTHEMASAGEHACapital Blue CrossComPsychFEPHEALTH ADVOCATE SOLUTIONSHighmark Blue Cross & Blue Shield of PennsylvaniaIBHLifeSolutions EAPLyra EAPMagellanMedicareMAZZITTI & SULLIVANMORNEAU SHEPELLOptum Behavior HealthOPTUM – EAPOptumHealthQuest Behavior HealthSpringHealth EAPTricareUnitedHealthcare
