Ground Zero Medical Billing & Consulting Services, LLC
AFFORDABLE & LOW COST MENTAL HEALTH AND MEDICAL BILLING

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Patient Information

Patient Contact Information
for Verification of Benefits
This contact form is provided for our client use only. Please use this secure form to enter information for verification of benefits. We will not use this information for any other purposes. Patient's please remember that the subscriber is usually the person paying the premium from their paycheck if the company is helping to pay for the insurance. Private insurance policies list the subscriber as the primary, whoever is first on the policy. We need the proper information to give the correct benefit information. This is a secure method of gathering information to assist the provider. 
Which provider are you seeing?:
First Name:
Last Name:
Social Security Number:
Date of Birth:
Address:
City:
State:
Zip Code:
Cell Phone:
Daytime Phone:
Email:
Insurance Company Telephone Number:
Insurance Company Name:
Policy ID#:
Group #:
Subscriber's Name:
Subscriber's Address:
Subscriber's City:
Subscriber's State:
Subscriber's Zip Code:
Subscriber's Date of Birth:
Subscriber's Social Number:

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