PATIENT BILLING AND INSURANCE FORM
Completing the information will allow us to accurately bill your insurance company on your behalf.

All fields must be completed to process your claim.
PATIENT INFORMATION
Patient's First Name:
Patient's Last Name:
Patient Acct Number:
Date of Birth:
SSN:
Email:
Address:
 
City:
State:
Zip Code:
Phone:
PRIMARY INSURANCE INFORMATION
Subscriber's Name:
Relation to Patient:
Employer:
Insurance Company:
ID #:
Group #:
Claims Address:
 
City:
State:
Zip Code:
Insurance Co Phone:
SECONDARY INSURANCE INFORMATION
Subscriber's Name:
Relation to Patient:
Employer:
Insurance Company:
ID #:
Group #:
Claims Address:
 
City:
State:
Zip Code:
Insurance Co Phone:
MISCELLANEOUS QUESTIONS AND COMMENTS
CONFIRM AND SUBMIT
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ClearPath Diagnostics  600 East Genesee Street, Suite 305,  Syracuse, NY 13202
Phone: (315) 234-3300  Toll Free: (866) 310-2406  Fax: (315) 234-3305
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