Insurance Submission Form

Please fill out your insurance details and upload your card images below.

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

Upload Document

SECURE PORTAL

Upload Your Cards

Secure File Transfer

Upload a copy of your insurance card, referral letter, or mental health records directly to our HIPAA-compliant system.

Please provide clear photos or PDF scans of the front and back of your insurance card. This helps our team verify your benefits quickly and accurately.

FAQs

What info is needed?

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

How to upload cards?

Use the upload buttons to submit front and back images of your insurance card.

What if I have secondary insurance?

You can enter secondary insurance details and upload those card images in the form.

Consent checkboxes confirm your understanding and responsibility.

Is my info secure?

Who to contact for help?

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

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: 571-389-1678

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

Outpatient Mental Health Practice

If you are in crisis, call or text 988 for the Suicide & Crisis Lifeline.