Securely Update Your Insurance Information
Back In Action Medical Center
Full Name
*
Date of birth
*
Policy Holders Billing Address
*
City
*
State
*
Zip code
*
Primary Insurance Company
*
Name of Policy Holder
*
Same as above
Other
Please enter the name of the policy holder if "other" was selected above.
Please select the relationship to the policy holder
*
Self
Mother
Father
Other
If "Other" was selected above please enter the relationship to the policy holder below
Subscriber Number
*
Group Number
*
Upload a copy of your insurance card [FRONT]
Upload a copy of your insurance card [BACK]
Please enter the name of your Secondary Insurance Company if applicable
Name of Secondary Policy Holder if applicable
Secondary Group Number if applicable
Secondary Subscriber Number if applicable
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