Insured or Responsible Party Information

If you have insurance, please provide the information requested below. This information will assist us in representing you when we discuss your claim with the medical provider. If you do not have insurance, we need the name of the responsible party, the person who will be paying the provider’s bill. To change any information, do so before selecting Save and Continue.

Responsible Party
(or Insured)
*  
Patient’s relationship to the Responsible Party/Insured
*  
Insured’s
(or Responsible Party’s)
Social Security No.
*  
e.g. 123-45-6789  
Insurance Information
 
Was the patient insured?
*  
Insurance Co. Name
Group ID
Member ID
How were you referred
to our service
Other Source
* Required


H.H.C. Group • 438 North Frederick Ave, #200A, Gaithersburg, MD 20877
consumer@hhcgroup.com
URAC