Insurance Submission Form

HIPAA‑Compliant Secure Form: Enter your insurance information to begin the verification process.

Full legal name*

Date of birth*

Address*

Your email*

Phone number*

Insurance provider name*

Plan type*

Member ID number*

Group number*

Policyholder name, date of birth & relationship to policyholder

Secondary Insurance (if applicable)

Do you have a deductible?

Yes

Unsure

Consent & Verification*

I confirm that the insurance information provided is accurate.

I understand that verification is required before my appointment is confirmed.

I agree to be responsible for any charges not covered by my insurance.

Insurance Consent & Authorization: I authorize this practice to use and share my protected health information (PHI) as needed for insurance verification, eligibility checks, billing, and payment. I understand I am responsible for any copays, deductibles, or non covered services, and I confirm that the insurance information I provided is accurate.*

Yes

FAQs

What info is needed?

Please provide your full legal name, DOB, contact, and address.

How or when will I upload my insurance card?

Our team reviews your information, verifies your insurance details, and reaches out with the next steps to continue your onboarding process.

What if I have secondary insurance?

You can enter secondary insurance details in the form.

Yes. All information you submit is protected through HIPAA‑compliant systems to ensure your privacy and security.

Is my info secure?

Who to contact for help?

Reach out via email or phone if you need assistance with the form.

What happens after submission?

After you complete the initial questionnaire, our team will contact you directly to request your insurance card and provide instructions for secure upload.

Accord Health & Wellness Services

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Feel free to contact us. We're here to support you always.

Email: contact@accordhealthwellness.com

Phone: (301) 298 2377; (571) 389 1678

Fax: (949) 695 4090; (301) 298 2376

Postal Address: 9103 Woodmore Centre Drive #634, Lanham, MD 20706

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