Insurance Payments

Billing Details
First Name*
Last Name*
Email Address*
Phone*
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Shipping*
Is your shipping address the same as your billing address?
- Yes, it is the same
- No, it is different
Shipping Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Patient Details
Patient Name*
First Last
Patient Email*
Patient Phone*
Patient Gender*
- Male
- Female
- Other
Patient Date of Birth*
Date Format: MM slash DD slash YYYY
Ordering Physician*
First Last
Did you see your provider at NUNM?*
- Yes, NUNM Health Center
- No, somewhere else
Insurance Carrier*
- Care Oregon
At this time we are ONLY contracted with CareOregon.
Insurance Details
Insurance Type*
Is this carrier your primary or secondary insurance?
- Primary
- Secondary
Insurance ID
Insurance Group Number
Insurance Medical Claims Address
Street Address Address Line 2 City State ZIP Code
Subscriber Name*
First Last
Subscriber Date of Birth*
Date Format: MM slash DD slash YYYY
Subscriber Gender*
- Male
- Female
- Other
Relationship to Patient*
- Self
- Spouse
- Parent
- Child
- Partner
- Other
Additional Information
The SIBO Center only submits claims for insurance reimbursement for contracted insurance plans. At this time we are ONLY contracted with CareOregon.

For all other insurances, you will need to pay for your kit out of pocket. We can provide you with a Billing Statement to self-submit to your insurance once we receive your completed test back. Please email sibolab@nunm.edu to request a Billing Statement, or include a note when you return your test.
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3025 SW Corbett Avenue, Portland, OR 97201503.552.1931

Billing Details

Patient Details

Insurance Details

Additional Information