Insurance Checkout Form

This form should ONLY be filled out if your primary OR secondary insurance carrier is Care Oregon or LifeWiseIf you are insured by a different carrier, checkout using the Other Forms of Payment option.

Shipping Details

Patient First & Last Name

Shipping Address

Shipping Town/City

Shipping State

Shipping Zip

Email

Patient Phone Number

Patient Gender

FemaleMaleOther

Patient DOB


Insurance Information

Note: All information must be filled out to bill the insurance carrier.

Insurance Carrier

Care OregonLifeWise

Is this carrier your primary or secondary insurance?

PrimarySecondary

Ordering Physician, First and Last Name

Insurance ID

Insurance Group #

Insurance Medical Claims Address

Insurance City

Insurance State

Insurance Zip

Subscriber Name (First & Last)

Subscriber DOB

Subscriber Gender

FemaleMaleOther

Relationship to Patient

SelfSpouseParentChildPartnerOther