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Healthcare & Wellness
Insurance Details Update
Collect current insurance information and card photos before the visit, so check-in takes seconds instead of a clipboard.
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Preview · not interactiveInsurance Details Update
Collect current insurance information and card photos before the visit, so check-in takes seconds instead of a clipboard.
Patient's name*
Exactly as it appears on your clinic record.
Patient's date of birth*
Pick a date📅
We use this to match your record — nothing else.
Insurance provider*
The company name on your card
Member / policy ID*
As printed on your card
Group number (if shown)
Leave blank if your card has none
Your relationship to the policyholder*
Select…▾
Policyholder's full name
As it appears on the policy
Photo of the FRONT of your insurance card*
Lay the card flat, fill the frame, and check the text is sharp — this is what saves you the clipboard.
Photo of the BACK of your insurance card*
The back usually carries claims and contact details we need.
Coverage effective date (if you know it)
Pick a date📅
Shown on newer cards or your policy documents — skip if unsure.
Do you have secondary insurance?
Yes
No
Secondary insurance details
Billing authorization*
Billing authorization
Submit