If you were unable to provide complete insurance information at the time of your treatment, you can use this secure form to submit information online. This will help us process your insurance claims and provide us with information for a more accurate billing statement.

If you prefer to submit information by phone, you can call the business office or a Fairview representative at the number on your statement.

Fields marked with an * are required.

Contact Information

*Name:

*Relationship to Patient:
Select Relationship Self Spouse Legal Guardian Other

*Daytime Phone:

Evening Phone:

Cell Phone:

Email:

Patient Information

*Patient Name:

*Patient Date of Birth:

*Account Number (See your billing statement):

Service Information

Please enter the date and Fairview clinic or hospital you visited. Please estimate if you do not know the exact date.

*Date of Service:

Fairview Hospital or Clinic:

Insurance Coverage

Please see your insurance card for this information.

Primary Insurance

*Type of Insurance:
Select Type Health Workman's Comp Auto Liability

*Insurance Company:
Select Insurance Company Blue Cross of MN Preferred One Health Partners Ucare Minnesota Medial Assistance Medicare Medica Other (fill in address below):

Name of Other Insurance Company:

Address (only required if Other is selected):

City:

State:
Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

*Subscriber/Member Name:

*Subscriber's Date of Birth:

*ID Number:

Effective Date:

Group Number/Name:

Secondary Insurance

Type of Insurance:
Select Type Health Workman's Comp Auto Liability

Secondary Insurance Company:
Select Insurance Company Blue Cross of MN Preferred One Health Partners Ucare Minnesota Medial Assistance Medicare Medica Other (fill in address below):

Name of Other Insurance Company:

Address (only required if Other is selected):

City:

State:
Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip:

Subscriber/Member Name:

Subscriber's Date of Birth:

ID Number:

Effective Date:

Group Number/Name: