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CT
DE
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ID
IL
IN
IA
KS
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ME
MD
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MS
MO
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NE
NV
NH
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NY
NC
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PA
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SD
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UT
VT
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VA
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Home Phone:
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Cell Phone
Other Phone
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Email
SSN
Email
Birthday
Occupation
Sex
Male
Female
Employment Status
Employed
Full-Time Student
Part-Time Student
Marital Status
Single
Married
Separated
Divorced
Widowed
Unknown
Employer/School Name
Primary Doctor
No Doctor Assigned
Dr. Lippas, Matthew
Misc/Guardian
Primary
Insurance Information
Insurance Name:
None
AARP Health Care Options
Accountable Health Plan
Accountable Health Plan
Accountable Health Plan
Advantra Freedom Medicare Advantage Plan
Aetna
Aetna
AFLAC
Alliance Health Medical Plans
Allied National
AMA Insurance
AmeriBen Solutions/PHCS
American Continental Insurance
American International Companies
American Medical Security
American Medical Security
American National Life Insurance
American Pioneer Life
American Republic Insurance
AmeriHealth Administrators
Anthem BCBS
Anthem Benefit Administrators
Anthem Blue Cross
APWU Health Plan
Assurant Health/PHCS
Assurant Health/PHCS
AVMA
Bankers Life and Casualty Company
BCBS
Beach Street
Benefit Planners
Benesight
Benesight/UnitedHealth
Benesight/Unitedhealthcare
Best Life Assurant
Blue Cross of California
Boon-Chapman
Bravo Health Texas, Inc
Care Improvement Plus
Care Improvement Plus
Caremark
Caremark/PHCS
Catalyst Office Group of Benefits
Celtic
Celtic Individual Health/PHCS
Central State Health & Life Co. Of Omaha
Central State Indemnity
Central States
Centry Health Insurance
CHAMPVA
Chesterfield Resources Inc.
Christian Fidelity
Cigna
Cigna
Cigna
Cigna
CIGNA H/CARE-UT SELECT
Cigna Health Care/CT
Cigna Healthcare
Cigna Healthcare
CIGNA HealthCare
CIGNA HealthCare
Cigna Healthcare/IA
CIGNA HealthCare/SC
Cigna Healthcare/TN
Cigna PPO
Cigna PPO
Cigna PPO/CT
Cigna/CA
Cigna/CA
Cigna/De
Cigna/Delta Pilots
CIGNA/GA
CIGNA/IL
CIGNA/OH
Cigna/PPO
CIGNA/PPO
CIGNA/PR
Cigna/Sherman
Cigna/TN
CIGNA/TN
CIGNA/TN
CIGNA/TN
CIGNA/TN
CIGNA/TN
CIGNA/TN
CIGNA/TN
CIGNA/TN
CIGNA/TX
Cinergy Health
Clampitt Paper Co.
CNA
CNA Group/Nashville
CNA Health Partners
CNA Ins./Ft. Worth
CNA Ins./Houston
CNC
Coast To Coast Vision Plan
Colonial Penn Ins. Co.
Combined
Combined Insurance
Combined Underwriters
Comprehensive Benefits
Concordia
Confed. Admin. Service
Connecticut General
Connecticut General
Connecticut General Life Insurance
Connecticut General/IA
Connecticut General/Ny
Connecticut General/Tx
Conseco
Conseco
Conseco Health Insurance Co
Consumer's Choice/USA/First Health
Continental General
Continental General
Continental General Insurance
Continental Life
Conventry Health Care
CoreSource
CoreSource, Inc./ PA
CoreSource/Kansas
CoreSource/PHCS/AZ
CoreSource/PHCS/KS
CoreSource/SFA PHCS
Corestar/PHCS
Coroplast/PHCS/MI
Corporate Benefits
Corporate Health Ad/Tx
Covenant Admin., Inc.
Crime Victims' Compensation Benefits
CUSTOMCARE
CustomCare/DFW Network
Dakotacare
Dallas Cowboys
Dallas General Life
Dallas General Life
Dallas General Life Ins
Dallas General Life Ins.
DAS, Inc
Definity Insurance
Dept. of Assistive & Rehab. Services
District Council 16
Dixie Yarns
Donovan Benefit Sys.
Dun & Bradstreet
E3 Health /PHCS
EastCore Inc.
EBP Health Plans, Inc.
EDS
Elige Administration & Ins.
Emdeon
Emloyers Claims Adj.Co
Employer Services
Employers Benefit Services
Employers Direct Health/PHCS
Employers Direct Health/PHCS
Employers Direct Health/PHCS
Employers Health Ins.
Entrust,Inc.
EPOCH Group
Equitable Life & Casualty
ERISA Admin. Services
ERS
Evercare
Evercare
FBMC
First Baptist Church
First Health
First Health
First Health
First Health
First Health
First Health
First Health
First Health Afford/Tx
First Health Insurance
First Health Network/PHCO
First Health/Afford/Ut
First Health/AZ
First Health/AZ
First Health/AZ
First Health/AZ
First Health/CUNA/WI
First Health/Ky
First Health/UT
First Integrated Healt
First National Life
FISERV HEALTH
FISERV HEALTH
Flex Net
FMH Benefit Services
Fortis Benefits
Fortis Benefits
Fortis Benefits(PHCS)
Fortis Ins/PHCS
FRA
Freedom Life Ins./PHCS
Freedom Life Insurance
Full Access
GAB Robins
Gallagher Bassett Services, Inc
Gallagher Benefit
Gallagher Benefit Adm.
Gallagher Benefit Adm.
GE Group Administrator
GE Health Manager
GEGA Association
GEHA
GEHA / ARIZONA
GEHA / MO
GEHA Association/MO
General American
General American/CA
General American/Mo
General American/PHCS
General American/SL MO
General American/TX
Genworth Life Insurance
GHI
Gilsbar Inc/PHCS
Glidden Company
Globe Life and Accident Insurance
Golden Rule Insurance
Golden Rule Insurance
Golden Rule Insurance
Good Samaritan Program
Goodyear Tire Company
Gospel Missionary Unio
GPA
GPA
GPA/PHCS
Great-West Life & Annu
Great-West One Health
Great-West POS
Great American Life Insurance
Great West/CO
Great West/One Health
Great West/PHCS
Great West/PHCS/COL
Great West/PHCS/SC
Group & Pension Admin.
Group & Pension Administrators
Group Resources Inc.
Group Resources/PHCS
Guardian
Guardian Life/NY
Guardian VG
Guardian/MA
Guardian/WI
GWH-Cigna
Harrington Benefit
Harrington Benefit
Harrington Benefit
Harrington Benefit Ser
Harrington Benefit Services
Harrington Benefit Services
Harrington Benefit Services
Harrington benefits/Aetna Signature
Harris Methodist Plan
Harris Methodist/Arlin
Hartford (Benefit Planners)
Hartford Ins.
Hartford Life Insurance
Hartford Life Insurance
Harvest Home Life
Health Admin. Services
Health Administrators
Health Administrators
Health Advantage
Health Aspex
Health Care Benefits
Health Choice
Health Comp
Health Design Plus
Health First
Health First
Health Link
Health Net
Health Net
Health Net Pearl
Health Net PPO
Health Net/ First Health
Health Partners
Health Plan Administrators, Inc.
Health SCOPE Benifits
Health Smart
Health Star
Health Tx/Secure Horz.
Healthaspex/ Diversified Group
HealthCare Compare
HealthMarket/PHCS
HealthPlan Services/PHCS
HealthSCOPE Benefits, Inc.
Healthsmart
HealthSmart
Healthsmart Preferred Care Ins
HealthSource Provident
Healthspring
HEB Health Share (Health Smart)
HighMark-BlueCross/BS
HMO-BLUE TEXAS
HMO Blue Texas
HMO Blue Texas
HMO Blue, Northeast Tx
Horshoe Casino-Sierra
Hospice Plus
HPS Paradigm
Humana
Humana
Humana
Humana
Humana
Humana HealthCare/KY
Humana/KY
Humana/SPA
HUMANA/WI
Hunt Benefit Plan
IAB Discount Plan
IAC
IBEW-NECA Southwestern
Icon Benefit Administrators
ICON Benefit Company
IMA of Louisiana
Incentus
Inova Healthcare
Insurance Center/PHCS
International Benefits
IPA, P.A.
J.P. Farley Corporation
Jefferson Pilot
Jefferson Pilot/Tx
JI Specialty Services
John Alden Health Ins.
John Alden Ins.
John Alden Life Ins Co/PHCS
John Alden Life Ins/ PHCS
John Hancock Ins
K & K Insurance
Kemper National Ser.
Kirk Van Orsdel
Kroger Health Benefits
KVI
Labcorp Benefits
Lamar Life/Tx 75380
Life Investors Ins.
Lincoln National
Loyal American Life Ins. Co.
LRAM GULF STATES
Lumenos/PHCS
Managed Care, Inc.
MassMutual
Medicaid
Medicaid/ Texas Star
Medicaid/NHIC
Medical Control
Medical Control Inc
Medical Control/NetOne
Medical Eye Services
Medicare Rail Road
Mediplus
Mega Life & Health
Mercy Health Plans
Meritain Health
Meritain Health PHCS
Met Life//Wi
Met Life/Pennzoil
Met Life/Pittsburgh
Met Life/TU Electric
MetLife HMO
MetLife Med Supplement
MetLife Network/Austin
MetLife Vision Care
MetLife/Coca-Cola
MetLife/GM
MetLife/IL
MetLife/LTV
MetLife/Sears
MetLife/Shell/Tx
MetraHealth
MetraHealth Care/TX
MetraHealth/Albany
MetraHealth/Amer Air
MetraHealth/AT&T Wire
MetraHealth/Dallas
MetraHealth/Matteson
MetraHealth/MI
MetraHealth/NC
MetraHealth/NY
MetraHealth/RI
Metrahealth/Tampa
Metrahealth/Trav/Utah
MetraHealth/Umbrella
Metropolitan Life Ins Co
Metropolitan Life Ins.
Metropolitan Life/NY
Mid-West National Life Ins/PHCS
Missouri Pacific Ins,
MO., KS., TX. Railroad
Molina
Monumental Life
Monumental Life Ins.
Mutual Assurance Admin.
Mutual Assurance Administrators
Mutual of Omaha
Mutual of Omaha
Mutual of Omaha
Mutual Of Omaha-Addiso
Mutual Of Omaha-Dallas
Mutual Of Omaha/Exclus
Mutual Of Omaha/NTHN
Mutual Of Omaha/OK
Mutual Of Omaha/Omaha
MVP Health Care
MVPPO
NALC
NALC-Cigna
National Assoc. Letter Carriers
National Auto Sprinkle
National Benefit Corp
National Elevator
National Found. Life
National Foundation Life Ins. Co.
National Home Life Ins
National States Insurance
Natl Health Ins Co
NetOne Select
Network Adm., Inc. PPO
New England Care
New Era Life Ins
New Era Life Ins.
New ERA Life Insurance
New Era Life Insurance Companies
New York Life Ins
NHIC
Nippon Life Insurance
North American
North American Benefit
North American Benefit
North Texas HealthCare
North Texas Specialty Physicians
Northwestern Mutual
Novitas Solutions, Inc.
NPPN/NY
NYLCARE-HMO
NYLCare 65 **
NylCare 65 HealthplSW
NylCare 65 HMO (SPA)
NylCare Passport PPO
NylCare Passport PPOSW
NYLCARE PPO-DISD
NYLCARE/TUHP
NylCarePassport PPO/CA
Old Surety Life
Old Surety Life Insurance Company
One Health Plan
One Health Plan
One Health Plan
One Health Plan
OptiCare
Oxford Health Plans
P.F.L. Insurance
P5 e. Health Services, Inc.
Pacific Care
Pacific Health Adms.
Pacific Life & Annuity/AZ
Pacific Life/Annuity
PacifiCare Life/Health
PacifiCare Of Texas
Pacificare Senior Supplement Plan
PacifiCare/PHCS
PacifiCare/PHCS
PacifiCare/SPA
Palmetto GBA Railroad Medicare
Pan American Life
PCA Health Plan(Austin
PCA Solutions/Fl.
PCA/HMO/SPA
PCS
Pennsylvania Life Insurance Co.
PHA Ins. Services
PHCO
PHCS
PHCS
PHCS Private Healthcare Systems
PHCS/ Kaiser Permanente Insurance Co.
PHCS/AZ
PHCS/CA
PHCS/Citizen's Managmt
PHCS/IL
PHCS/IL
PHCS/Mercer Administration
PHCS/MO
PHCS/MO
PHCS/NC
PHCS/ReliaStar
PHCS/Trustmark
PHCS/TX
Philadelphia American Life
PHL(PHCS)
Phoenix Group Services
Phoenix Home Life/PHCS
Phoenix Mutual Life In
Physicians Mut Ins
Physicians Mutual
Physicians Mutual
Physicians Mutual
Physicians Mutual Ins.
Pinnacle Claims Management
Pioneer Life
Pioneer Management
Plano ISD
PM Group
PM Group
Pollocka Paper Distributors
Preferred Care
Preferred Care
Preferred Plan
Premier Benefits
Premier Medicare Sup.
Premier(PHCS)
Principal Financial Group
Principal Financial Grp/CO
Principal Health-IL
Principal Life Ins Co
Principal Life Ins. Co
Principal Life Insurance Co
Private Healthcare Systems
Pro-Net
Pro America
Pro America Network
Protective Insurance
Provident (Affordable)
Provident American Life
Provident American Life and Health Ins.
Provident Life & Acc
Provident Life & Acci
Provident/Chattanooga
Prudential-Health PPO
Prudential-PPO/CA
Prudential-PruNetwork
Prudential Group Healt
Prudential Health/HMO
Prudential Health/NJ
Prudential HealthCare
Prudential HMO/CUSTOM
Prudential Ins. Co/NY
Prudential Ins./IL
Prudential Ins./N.J.
Prudential Ins./Tx.
Prudential Ins/Anuity
Prudential Insurace Co of America
Prudential Network/CA
Prudential POS/HMO
Prudential/AT&T/Mo.
Prudential/AT&T/OH
Prudential/ATT/Fl.
PRUDENTIAL/ATT/NJ
Prudential/Care 90's
Prudential/CC/Mo
Prudential/Coca Cola
Prudential/Fl
Prudential/Glidden
Prudential/IBM
Prudential/S.A.., Tx
Prudential/TMA
PruNetwork
PruNetwork/Lucent
Pyramid Life Ins. Co.
Pyramid Life Insurance
Qual Choice
Railroad/Medicare
Reagit Ins./Affordable
Religious Comprehensive Trust
Reserve National Ins.
Reserve National Insurance
Retiree Medical Insurance
RH Admin. Inc., SPDDS
Risk Management
Rockwell, Claims Dept.
Royal Neighbors Of America
Rscko
Rural Carrier Benefit
SAG- Producers Health Plan
Samba
Samba
SAMBA
Scranton Ins
Secure Horiz/Pacifcare
Secure Horizons
Secure Horizons
Secure Horizons
Secure Horizons Direct
Secure Horizons/MMU
Secure Horizons/SPA
SecureHorizons
SecureHorizons/Medicare supplement
Senior Dimensions
Senior Health Service Center
Sentry Insurance
Shaw Medical/Acordia/PHCS
Sheet Metal Workers FU
Sierra Health & Life
Sierra Health and Life
Sierra/Olympic Health Mgmt
Sim USA
SKF USA Inc./ The loomis co.
Southern Benefits Con
Southwest Preferred
Southwest Service Life Insurance Company
Southwestern Financial
Southwire Company
SPA/DISD Claims
SPA/Mutual Of Omaha
Special Insurance Services
St.John's Claims Administration
Standar Life and Accident Insurance Comp
Standard Financial
Standard Life & Acc
Standard Life & Accident Insurance
Standard Life & Casualty
Standard Life and Accident
Standard Life Insurance
Starmark/PHCS
State Bar Of Texas
State Farm Health Ins
State Farm Health Ins/CO
State Farm Health Insurance
State Farm Health Insurance
State Farm Health Insurance
State Farm Ins
State Farm Ins.
State Farm Ins./Texas
State Farm Ins/IA
State Mutal Insurance Co.
State Mutual Ins. Co.
Sterling Ins.
Sterling Medicare Select
Sterling Plumbing Grp
Sterling Premier
Stonebridge Life
Superior Health Plan
T & C/ProAmerica
T.A.S.B. Insurance
TeamCare (PHCS)
Teamsters Benefit Trust
Texan Plus
Texas Dental Assoc.
Texas Health Choice
Texas Medical Association Ins
Texas Pipe Trades
Texas True Choice
Texas True Choice
The Covenant Group
The Empire Plan
The Goodyear Tire & Rubber Co
The Grotenhuis Group
The Guardian/PHCS/AZ
The Guardian/PHCS/WA
The Guardian/PHCS/WI
The Guardian/WI
The Mail Handlers Benefit Plan
The Mail Handlers Benefit Plan
The Mega Life Insurance Company PHCS
The Principal
The Principal
The Principal (IA)
The Principal Group
The Principal HMO-3426
The Principal Life Ins
The Prudential/FL
The Prudential/NJ
The Pyramid Life Insurance Company
The Reliable Insuranc
The Senior Health Plan
The Travelers/CT
The UCIP Program
The United States Life Ins.
Third Party Ad.Garland
Third Party Adm./Arlin
Thrivent Finicial
TI/Affordable
Time Insurance
Time Insurance Co
TML Group
TML IEBP
Total Plan Services
Total Plan Services Inc./ PHCS
Tower Life Insurance Company
TPA
TPA, Inc.
TPA/United Health
TPA/United Health/IL
TPA/UnitedHealthCar AZ
TPA/UnitedHealthCar TN
Transamerica Life Insurance Company
Travelers
Travelers Ins
Travelers Ins./Albany
Travelers Insurance Co
TRICARE
Tricare For Life
Trigon BCBS Of Va.
Trustmark
Trustmark
TrustMark
Trustmark/PHCS
Tucker & Clark(PPO)
Tx Life Accident Healt
U.C.T. Travelers
UFM International
UICI Administrators
UMR
UMR
UMR
UMR
Unicare
Unicare
Unicare
Unicare
UniCare
UniCare
UniCare
UNICARE-Classic/Baylor
UniCare-Medicare Supp
UNICARE-VAN NUYS
Unicare Classic
UNICARE Life & Health
Unicare/CT
Unicare/IL
UniCare/IL
UniCare/Ma
UniCare/MA
Unicare/MI
UNICARE/OXNARD
Unicare/TX
Unicare/Wellpoint NetW
Union Bankers
Union Fidelity Life
Union Fidelity Med. S
Union Security Ins. Co. /PHCS
United American Ins
United American Insurance
United Benefit Life
United Commercial Travelers
United Health Care
United Health Integrated Services
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare/GA
United of Omaha Life Insurance Co.
United Teacher Associates
United Teachers Associates
United Teachers Associates Insurance Company
Universal Health Care Insurance
USAA Life Insurance
UTA
Wausau Insurance
Web TPA
WellCare
Western & Southern
Insurance ID:
Insurance Policy Group:
Not Primary on Account:
Not Primary
Primary on Account
Name:
Last, First MI
Relationship to Insured:
Spouse
Child
Other
Sex:
Male
Female
Address:
City:
State:
Zip:
Phone Number:
Birthday:
SSN:
Employer/School:
Supplemental
Insurance Information
Insurance Name:
None
AARP Health Care Options
Accountable Health Plan
Accountable Health Plan
Accountable Health Plan
Advantra Freedom Medicare Advantage Plan
Aetna
Aetna
AFLAC
Alliance Health Medical Plans
Allied National
AMA Insurance
AmeriBen Solutions/PHCS
American Continental Insurance
American International Companies
American Medical Security
American Medical Security
American National Life Insurance
American Pioneer Life
American Republic Insurance
AmeriHealth Administrators
Anthem BCBS
Anthem Benefit Administrators
Anthem Blue Cross
APWU Health Plan
Assurant Health/PHCS
Assurant Health/PHCS
AVMA
Bankers Life and Casualty Company
BCBS
Beach Street
Benefit Planners
Benesight
Benesight/UnitedHealth
Benesight/Unitedhealthcare
Best Life Assurant
Blue Cross of California
Boon-Chapman
Bravo Health Texas, Inc
Care Improvement Plus
Care Improvement Plus
Caremark
Caremark/PHCS
Catalyst Office Group of Benefits
Celtic
Celtic Individual Health/PHCS
Central State Health & Life Co. Of Omaha
Central State Indemnity
Central States
Centry Health Insurance
CHAMPVA
Chesterfield Resources Inc.
Christian Fidelity
Cigna
Cigna
Cigna
Cigna
CIGNA H/CARE-UT SELECT
Cigna Health Care/CT
Cigna Healthcare
Cigna Healthcare
CIGNA HealthCare
CIGNA HealthCare
Cigna Healthcare/IA
CIGNA HealthCare/SC
Cigna Healthcare/TN
Cigna PPO
Cigna PPO
Cigna PPO/CT
Cigna/CA
Cigna/CA
Cigna/De
Cigna/Delta Pilots
CIGNA/GA
CIGNA/IL
CIGNA/OH
Cigna/PPO
CIGNA/PPO
CIGNA/PR
Cigna/Sherman
Cigna/TN
CIGNA/TN
CIGNA/TN
CIGNA/TN
CIGNA/TN
CIGNA/TN
CIGNA/TN
CIGNA/TN
CIGNA/TN
CIGNA/TX
Cinergy Health
Clampitt Paper Co.
CNA
CNA Group/Nashville
CNA Health Partners
CNA Ins./Ft. Worth
CNA Ins./Houston
CNC
Coast To Coast Vision Plan
Colonial Penn Ins. Co.
Combined
Combined Insurance
Combined Underwriters
Comprehensive Benefits
Concordia
Confed. Admin. Service
Connecticut General
Connecticut General
Connecticut General Life Insurance
Connecticut General/IA
Connecticut General/Ny
Connecticut General/Tx
Conseco
Conseco
Conseco Health Insurance Co
Consumer's Choice/USA/First Health
Continental General
Continental General
Continental General Insurance
Continental Life
Conventry Health Care
CoreSource
CoreSource, Inc./ PA
CoreSource/Kansas
CoreSource/PHCS/AZ
CoreSource/PHCS/KS
CoreSource/SFA PHCS
Corestar/PHCS
Coroplast/PHCS/MI
Corporate Benefits
Corporate Health Ad/Tx
Covenant Admin., Inc.
Crime Victims' Compensation Benefits
CUSTOMCARE
CustomCare/DFW Network
Dakotacare
Dallas Cowboys
Dallas General Life
Dallas General Life
Dallas General Life Ins
Dallas General Life Ins.
DAS, Inc
Definity Insurance
Dept. of Assistive & Rehab. Services
District Council 16
Dixie Yarns
Donovan Benefit Sys.
Dun & Bradstreet
E3 Health /PHCS
EastCore Inc.
EBP Health Plans, Inc.
EDS
Elige Administration & Ins.
Emdeon
Emloyers Claims Adj.Co
Employer Services
Employers Benefit Services
Employers Direct Health/PHCS
Employers Direct Health/PHCS
Employers Direct Health/PHCS
Employers Health Ins.
Entrust,Inc.
EPOCH Group
Equitable Life & Casualty
ERISA Admin. Services
ERS
Evercare
Evercare
FBMC
First Baptist Church
First Health
First Health
First Health
First Health
First Health
First Health
First Health
First Health Afford/Tx
First Health Insurance
First Health Network/PHCO
First Health/Afford/Ut
First Health/AZ
First Health/AZ
First Health/AZ
First Health/AZ
First Health/CUNA/WI
First Health/Ky
First Health/UT
First Integrated Healt
First National Life
FISERV HEALTH
FISERV HEALTH
Flex Net
FMH Benefit Services
Fortis Benefits
Fortis Benefits
Fortis Benefits(PHCS)
Fortis Ins/PHCS
FRA
Freedom Life Ins./PHCS
Freedom Life Insurance
Full Access
GAB Robins
Gallagher Bassett Services, Inc
Gallagher Benefit
Gallagher Benefit Adm.
Gallagher Benefit Adm.
GE Group Administrator
GE Health Manager
GEGA Association
GEHA
GEHA / ARIZONA
GEHA / MO
GEHA Association/MO
General American
General American/CA
General American/Mo
General American/PHCS
General American/SL MO
General American/TX
Genworth Life Insurance
GHI
Gilsbar Inc/PHCS
Glidden Company
Globe Life and Accident Insurance
Golden Rule Insurance
Golden Rule Insurance
Golden Rule Insurance
Good Samaritan Program
Goodyear Tire Company
Gospel Missionary Unio
GPA
GPA
GPA/PHCS
Great-West Life & Annu
Great-West One Health
Great-West POS
Great American Life Insurance
Great West/CO
Great West/One Health
Great West/PHCS
Great West/PHCS/COL
Great West/PHCS/SC
Group & Pension Admin.
Group & Pension Administrators
Group Resources Inc.
Group Resources/PHCS
Guardian
Guardian Life/NY
Guardian VG
Guardian/MA
Guardian/WI
GWH-Cigna
Harrington Benefit
Harrington Benefit
Harrington Benefit
Harrington Benefit Ser
Harrington Benefit Services
Harrington Benefit Services
Harrington Benefit Services
Harrington benefits/Aetna Signature
Harris Methodist Plan
Harris Methodist/Arlin
Hartford (Benefit Planners)
Hartford Ins.
Hartford Life Insurance
Hartford Life Insurance
Harvest Home Life
Health Admin. Services
Health Administrators
Health Administrators
Health Advantage
Health Aspex
Health Care Benefits
Health Choice
Health Comp
Health Design Plus
Health First
Health First
Health Link
Health Net
Health Net
Health Net Pearl
Health Net PPO
Health Net/ First Health
Health Partners
Health Plan Administrators, Inc.
Health SCOPE Benifits
Health Smart
Health Star
Health Tx/Secure Horz.
Healthaspex/ Diversified Group
HealthCare Compare
HealthMarket/PHCS
HealthPlan Services/PHCS
HealthSCOPE Benefits, Inc.
Healthsmart
HealthSmart
Healthsmart Preferred Care Ins
HealthSource Provident
Healthspring
HEB Health Share (Health Smart)
HighMark-BlueCross/BS
HMO-BLUE TEXAS
HMO Blue Texas
HMO Blue Texas
HMO Blue, Northeast Tx
Horshoe Casino-Sierra
Hospice Plus
HPS Paradigm
Humana
Humana
Humana
Humana
Humana
Humana HealthCare/KY
Humana/KY
Humana/SPA
HUMANA/WI
Hunt Benefit Plan
IAB Discount Plan
IAC
IBEW-NECA Southwestern
Icon Benefit Administrators
ICON Benefit Company
IMA of Louisiana
Incentus
Inova Healthcare
Insurance Center/PHCS
International Benefits
IPA, P.A.
J.P. Farley Corporation
Jefferson Pilot
Jefferson Pilot/Tx
JI Specialty Services
John Alden Health Ins.
John Alden Ins.
John Alden Life Ins Co/PHCS
John Alden Life Ins/ PHCS
John Hancock Ins
K & K Insurance
Kemper National Ser.
Kirk Van Orsdel
Kroger Health Benefits
KVI
Labcorp Benefits
Lamar Life/Tx 75380
Life Investors Ins.
Lincoln National
Loyal American Life Ins. Co.
LRAM GULF STATES
Lumenos/PHCS
Managed Care, Inc.
MassMutual
Medicaid
Medicaid/ Texas Star
Medicaid/NHIC
Medical Control
Medical Control Inc
Medical Control/NetOne
Medical Eye Services
Medicare Rail Road
Mediplus
Mega Life & Health
Mercy Health Plans
Meritain Health
Meritain Health PHCS
Met Life//Wi
Met Life/Pennzoil
Met Life/Pittsburgh
Met Life/TU Electric
MetLife HMO
MetLife Med Supplement
MetLife Network/Austin
MetLife Vision Care
MetLife/Coca-Cola
MetLife/GM
MetLife/IL
MetLife/LTV
MetLife/Sears
MetLife/Shell/Tx
MetraHealth
MetraHealth Care/TX
MetraHealth/Albany
MetraHealth/Amer Air
MetraHealth/AT&T Wire
MetraHealth/Dallas
MetraHealth/Matteson
MetraHealth/MI
MetraHealth/NC
MetraHealth/NY
MetraHealth/RI
Metrahealth/Tampa
Metrahealth/Trav/Utah
MetraHealth/Umbrella
Metropolitan Life Ins Co
Metropolitan Life Ins.
Metropolitan Life/NY
Mid-West National Life Ins/PHCS
Missouri Pacific Ins,
MO., KS., TX. Railroad
Molina
Monumental Life
Monumental Life Ins.
Mutual Assurance Admin.
Mutual Assurance Administrators
Mutual of Omaha
Mutual of Omaha
Mutual of Omaha
Mutual Of Omaha-Addiso
Mutual Of Omaha-Dallas
Mutual Of Omaha/Exclus
Mutual Of Omaha/NTHN
Mutual Of Omaha/OK
Mutual Of Omaha/Omaha
MVP Health Care
MVPPO
NALC
NALC-Cigna
National Assoc. Letter Carriers
National Auto Sprinkle
National Benefit Corp
National Elevator
National Found. Life
National Foundation Life Ins. Co.
National Home Life Ins
National States Insurance
Natl Health Ins Co
NetOne Select
Network Adm., Inc. PPO
New England Care
New Era Life Ins
New Era Life Ins.
New ERA Life Insurance
New Era Life Insurance Companies
New York Life Ins
NHIC
Nippon Life Insurance
North American
North American Benefit
North American Benefit
North Texas HealthCare
North Texas Specialty Physicians
Northwestern Mutual
Novitas Solutions, Inc.
NPPN/NY
NYLCARE-HMO
NYLCare 65 **
NylCare 65 HealthplSW
NylCare 65 HMO (SPA)
NylCare Passport PPO
NylCare Passport PPOSW
NYLCARE PPO-DISD
NYLCARE/TUHP
NylCarePassport PPO/CA
Old Surety Life
Old Surety Life Insurance Company
One Health Plan
One Health Plan
One Health Plan
One Health Plan
OptiCare
Oxford Health Plans
P.F.L. Insurance
P5 e. Health Services, Inc.
Pacific Care
Pacific Health Adms.
Pacific Life & Annuity/AZ
Pacific Life/Annuity
PacifiCare Life/Health
PacifiCare Of Texas
Pacificare Senior Supplement Plan
PacifiCare/PHCS
PacifiCare/PHCS
PacifiCare/SPA
Palmetto GBA Railroad Medicare
Pan American Life
PCA Health Plan(Austin
PCA Solutions/Fl.
PCA/HMO/SPA
PCS
Pennsylvania Life Insurance Co.
PHA Ins. Services
PHCO
PHCS
PHCS
PHCS Private Healthcare Systems
PHCS/ Kaiser Permanente Insurance Co.
PHCS/AZ
PHCS/CA
PHCS/Citizen's Managmt
PHCS/IL
PHCS/IL
PHCS/Mercer Administration
PHCS/MO
PHCS/MO
PHCS/NC
PHCS/ReliaStar
PHCS/Trustmark
PHCS/TX
Philadelphia American Life
PHL(PHCS)
Phoenix Group Services
Phoenix Home Life/PHCS
Phoenix Mutual Life In
Physicians Mut Ins
Physicians Mutual
Physicians Mutual
Physicians Mutual
Physicians Mutual Ins.
Pinnacle Claims Management
Pioneer Life
Pioneer Management
Plano ISD
PM Group
PM Group
Pollocka Paper Distributors
Preferred Care
Preferred Care
Preferred Plan
Premier Benefits
Premier Medicare Sup.
Premier(PHCS)
Principal Financial Group
Principal Financial Grp/CO
Principal Health-IL
Principal Life Ins Co
Principal Life Ins. Co
Principal Life Insurance Co
Private Healthcare Systems
Pro-Net
Pro America
Pro America Network
Protective Insurance
Provident (Affordable)
Provident American Life
Provident American Life and Health Ins.
Provident Life & Acc
Provident Life & Acci
Provident/Chattanooga
Prudential-Health PPO
Prudential-PPO/CA
Prudential-PruNetwork
Prudential Group Healt
Prudential Health/HMO
Prudential Health/NJ
Prudential HealthCare
Prudential HMO/CUSTOM
Prudential Ins. Co/NY
Prudential Ins./IL
Prudential Ins./N.J.
Prudential Ins./Tx.
Prudential Ins/Anuity
Prudential Insurace Co of America
Prudential Network/CA
Prudential POS/HMO
Prudential/AT&T/Mo.
Prudential/AT&T/OH
Prudential/ATT/Fl.
PRUDENTIAL/ATT/NJ
Prudential/Care 90's
Prudential/CC/Mo
Prudential/Coca Cola
Prudential/Fl
Prudential/Glidden
Prudential/IBM
Prudential/S.A.., Tx
Prudential/TMA
PruNetwork
PruNetwork/Lucent
Pyramid Life Ins. Co.
Pyramid Life Insurance
Qual Choice
Railroad/Medicare
Reagit Ins./Affordable
Religious Comprehensive Trust
Reserve National Ins.
Reserve National Insurance
Retiree Medical Insurance
RH Admin. Inc., SPDDS
Risk Management
Rockwell, Claims Dept.
Royal Neighbors Of America
Rscko
Rural Carrier Benefit
SAG- Producers Health Plan
Samba
Samba
SAMBA
Scranton Ins
Secure Horiz/Pacifcare
Secure Horizons
Secure Horizons
Secure Horizons
Secure Horizons Direct
Secure Horizons/MMU
Secure Horizons/SPA
SecureHorizons
SecureHorizons/Medicare supplement
Senior Dimensions
Senior Health Service Center
Sentry Insurance
Shaw Medical/Acordia/PHCS
Sheet Metal Workers FU
Sierra Health & Life
Sierra Health and Life
Sierra/Olympic Health Mgmt
Sim USA
SKF USA Inc./ The loomis co.
Southern Benefits Con
Southwest Preferred
Southwest Service Life Insurance Company
Southwestern Financial
Southwire Company
SPA/DISD Claims
SPA/Mutual Of Omaha
Special Insurance Services
St.John's Claims Administration
Standar Life and Accident Insurance Comp
Standard Financial
Standard Life & Acc
Standard Life & Accident Insurance
Standard Life & Casualty
Standard Life and Accident
Standard Life Insurance
Starmark/PHCS
State Bar Of Texas
State Farm Health Ins
State Farm Health Ins/CO
State Farm Health Insurance
State Farm Health Insurance
State Farm Health Insurance
State Farm Ins
State Farm Ins.
State Farm Ins./Texas
State Farm Ins/IA
State Mutal Insurance Co.
State Mutual Ins. Co.
Sterling Ins.
Sterling Medicare Select
Sterling Plumbing Grp
Sterling Premier
Stonebridge Life
Superior Health Plan
T & C/ProAmerica
T.A.S.B. Insurance
TeamCare (PHCS)
Teamsters Benefit Trust
Texan Plus
Texas Dental Assoc.
Texas Health Choice
Texas Medical Association Ins
Texas Pipe Trades
Texas True Choice
Texas True Choice
The Covenant Group
The Empire Plan
The Goodyear Tire & Rubber Co
The Grotenhuis Group
The Guardian/PHCS/AZ
The Guardian/PHCS/WA
The Guardian/PHCS/WI
The Guardian/WI
The Mail Handlers Benefit Plan
The Mail Handlers Benefit Plan
The Mega Life Insurance Company PHCS
The Principal
The Principal
The Principal (IA)
The Principal Group
The Principal HMO-3426
The Principal Life Ins
The Prudential/FL
The Prudential/NJ
The Pyramid Life Insurance Company
The Reliable Insuranc
The Senior Health Plan
The Travelers/CT
The UCIP Program
The United States Life Ins.
Third Party Ad.Garland
Third Party Adm./Arlin
Thrivent Finicial
TI/Affordable
Time Insurance
Time Insurance Co
TML Group
TML IEBP
Total Plan Services
Total Plan Services Inc./ PHCS
Tower Life Insurance Company
TPA
TPA, Inc.
TPA/United Health
TPA/United Health/IL
TPA/UnitedHealthCar AZ
TPA/UnitedHealthCar TN
Transamerica Life Insurance Company
Travelers
Travelers Ins
Travelers Ins./Albany
Travelers Insurance Co
TRICARE
Tricare For Life
Trigon BCBS Of Va.
Trustmark
Trustmark
TrustMark
Trustmark/PHCS
Tucker & Clark(PPO)
Tx Life Accident Healt
U.C.T. Travelers
UFM International
UICI Administrators
UMR
UMR
UMR
UMR
Unicare
Unicare
Unicare
Unicare
UniCare
UniCare
UniCare
UNICARE-Classic/Baylor
UniCare-Medicare Supp
UNICARE-VAN NUYS
Unicare Classic
UNICARE Life & Health
Unicare/CT
Unicare/IL
UniCare/IL
UniCare/Ma
UniCare/MA
Unicare/MI
UNICARE/OXNARD
Unicare/TX
Unicare/Wellpoint NetW
Union Bankers
Union Fidelity Life
Union Fidelity Med. S
Union Security Ins. Co. /PHCS
United American Ins
United American Insurance
United Benefit Life
United Commercial Travelers
United Health Care
United Health Integrated Services
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare/GA
United of Omaha Life Insurance Co.
United Teacher Associates
United Teachers Associates
United Teachers Associates Insurance Company
Universal Health Care Insurance
USAA Life Insurance
UTA
Wausau Insurance
Web TPA
WellCare
Western & Southern
Insurance ID:
Insurance Policy Group:
Not Primary on Account:
Not Primary
Primary on Account
Name:
Last, First MI
Relationship to Insured:
Spouse
Child
Other
Sex:
Male
Female
Address:
City:
State:
Zip:
Phone Number:
Birthday:
SSN:
Employer/School:
Tertiary
Insurance Information
Insurance Name:
None
AARP Health Care Options
Accountable Health Plan
Accountable Health Plan
Accountable Health Plan
Advantra Freedom Medicare Advantage Plan
Aetna
Aetna
AFLAC
Alliance Health Medical Plans
Allied National
AMA Insurance
AmeriBen Solutions/PHCS
American Continental Insurance
American International Companies
American Medical Security
American Medical Security
American National Life Insurance
American Pioneer Life
American Republic Insurance
AmeriHealth Administrators
Anthem BCBS
Anthem Benefit Administrators
Anthem Blue Cross
APWU Health Plan
Assurant Health/PHCS
Assurant Health/PHCS
AVMA
Bankers Life and Casualty Company
BCBS
Beach Street
Benefit Planners
Benesight
Benesight/UnitedHealth
Benesight/Unitedhealthcare
Best Life Assurant
Blue Cross of California
Boon-Chapman
Bravo Health Texas, Inc
Care Improvement Plus
Care Improvement Plus
Caremark
Caremark/PHCS
Catalyst Office Group of Benefits
Celtic
Celtic Individual Health/PHCS
Central State Health & Life Co. Of Omaha
Central State Indemnity
Central States
Centry Health Insurance
CHAMPVA
Chesterfield Resources Inc.
Christian Fidelity
Cigna
Cigna
Cigna
Cigna
CIGNA H/CARE-UT SELECT
Cigna Health Care/CT
Cigna Healthcare
Cigna Healthcare
CIGNA HealthCare
CIGNA HealthCare
Cigna Healthcare/IA
CIGNA HealthCare/SC
Cigna Healthcare/TN
Cigna PPO
Cigna PPO
Cigna PPO/CT
Cigna/CA
Cigna/CA
Cigna/De
Cigna/Delta Pilots
CIGNA/GA
CIGNA/IL
CIGNA/OH
Cigna/PPO
CIGNA/PPO
CIGNA/PR
Cigna/Sherman
Cigna/TN
CIGNA/TN
CIGNA/TN
CIGNA/TN
CIGNA/TN
CIGNA/TN
CIGNA/TN
CIGNA/TN
CIGNA/TN
CIGNA/TX
Cinergy Health
Clampitt Paper Co.
CNA
CNA Group/Nashville
CNA Health Partners
CNA Ins./Ft. Worth
CNA Ins./Houston
CNC
Coast To Coast Vision Plan
Colonial Penn Ins. Co.
Combined
Combined Insurance
Combined Underwriters
Comprehensive Benefits
Concordia
Confed. Admin. Service
Connecticut General
Connecticut General
Connecticut General Life Insurance
Connecticut General/IA
Connecticut General/Ny
Connecticut General/Tx
Conseco
Conseco
Conseco Health Insurance Co
Consumer's Choice/USA/First Health
Continental General
Continental General
Continental General Insurance
Continental Life
Conventry Health Care
CoreSource
CoreSource, Inc./ PA
CoreSource/Kansas
CoreSource/PHCS/AZ
CoreSource/PHCS/KS
CoreSource/SFA PHCS
Corestar/PHCS
Coroplast/PHCS/MI
Corporate Benefits
Corporate Health Ad/Tx
Covenant Admin., Inc.
Crime Victims' Compensation Benefits
CUSTOMCARE
CustomCare/DFW Network
Dakotacare
Dallas Cowboys
Dallas General Life
Dallas General Life
Dallas General Life Ins
Dallas General Life Ins.
DAS, Inc
Definity Insurance
Dept. of Assistive & Rehab. Services
District Council 16
Dixie Yarns
Donovan Benefit Sys.
Dun & Bradstreet
E3 Health /PHCS
EastCore Inc.
EBP Health Plans, Inc.
EDS
Elige Administration & Ins.
Emdeon
Emloyers Claims Adj.Co
Employer Services
Employers Benefit Services
Employers Direct Health/PHCS
Employers Direct Health/PHCS
Employers Direct Health/PHCS
Employers Health Ins.
Entrust,Inc.
EPOCH Group
Equitable Life & Casualty
ERISA Admin. Services
ERS
Evercare
Evercare
FBMC
First Baptist Church
First Health
First Health
First Health
First Health
First Health
First Health
First Health
First Health Afford/Tx
First Health Insurance
First Health Network/PHCO
First Health/Afford/Ut
First Health/AZ
First Health/AZ
First Health/AZ
First Health/AZ
First Health/CUNA/WI
First Health/Ky
First Health/UT
First Integrated Healt
First National Life
FISERV HEALTH
FISERV HEALTH
Flex Net
FMH Benefit Services
Fortis Benefits
Fortis Benefits
Fortis Benefits(PHCS)
Fortis Ins/PHCS
FRA
Freedom Life Ins./PHCS
Freedom Life Insurance
Full Access
GAB Robins
Gallagher Bassett Services, Inc
Gallagher Benefit
Gallagher Benefit Adm.
Gallagher Benefit Adm.
GE Group Administrator
GE Health Manager
GEGA Association
GEHA
GEHA / ARIZONA
GEHA / MO
GEHA Association/MO
General American
General American/CA
General American/Mo
General American/PHCS
General American/SL MO
General American/TX
Genworth Life Insurance
GHI
Gilsbar Inc/PHCS
Glidden Company
Globe Life and Accident Insurance
Golden Rule Insurance
Golden Rule Insurance
Golden Rule Insurance
Good Samaritan Program
Goodyear Tire Company
Gospel Missionary Unio
GPA
GPA
GPA/PHCS
Great-West Life & Annu
Great-West One Health
Great-West POS
Great American Life Insurance
Great West/CO
Great West/One Health
Great West/PHCS
Great West/PHCS/COL
Great West/PHCS/SC
Group & Pension Admin.
Group & Pension Administrators
Group Resources Inc.
Group Resources/PHCS
Guardian
Guardian Life/NY
Guardian VG
Guardian/MA
Guardian/WI
GWH-Cigna
Harrington Benefit
Harrington Benefit
Harrington Benefit
Harrington Benefit Ser
Harrington Benefit Services
Harrington Benefit Services
Harrington Benefit Services
Harrington benefits/Aetna Signature
Harris Methodist Plan
Harris Methodist/Arlin
Hartford (Benefit Planners)
Hartford Ins.
Hartford Life Insurance
Hartford Life Insurance
Harvest Home Life
Health Admin. Services
Health Administrators
Health Administrators
Health Advantage
Health Aspex
Health Care Benefits
Health Choice
Health Comp
Health Design Plus
Health First
Health First
Health Link
Health Net
Health Net
Health Net Pearl
Health Net PPO
Health Net/ First Health
Health Partners
Health Plan Administrators, Inc.
Health SCOPE Benifits
Health Smart
Health Star
Health Tx/Secure Horz.
Healthaspex/ Diversified Group
HealthCare Compare
HealthMarket/PHCS
HealthPlan Services/PHCS
HealthSCOPE Benefits, Inc.
Healthsmart
HealthSmart
Healthsmart Preferred Care Ins
HealthSource Provident
Healthspring
HEB Health Share (Health Smart)
HighMark-BlueCross/BS
HMO-BLUE TEXAS
HMO Blue Texas
HMO Blue Texas
HMO Blue, Northeast Tx
Horshoe Casino-Sierra
Hospice Plus
HPS Paradigm
Humana
Humana
Humana
Humana
Humana
Humana HealthCare/KY
Humana/KY
Humana/SPA
HUMANA/WI
Hunt Benefit Plan
IAB Discount Plan
IAC
IBEW-NECA Southwestern
Icon Benefit Administrators
ICON Benefit Company
IMA of Louisiana
Incentus
Inova Healthcare
Insurance Center/PHCS
International Benefits
IPA, P.A.
J.P. Farley Corporation
Jefferson Pilot
Jefferson Pilot/Tx
JI Specialty Services
John Alden Health Ins.
John Alden Ins.
John Alden Life Ins Co/PHCS
John Alden Life Ins/ PHCS
John Hancock Ins
K & K Insurance
Kemper National Ser.
Kirk Van Orsdel
Kroger Health Benefits
KVI
Labcorp Benefits
Lamar Life/Tx 75380
Life Investors Ins.
Lincoln National
Loyal American Life Ins. Co.
LRAM GULF STATES
Lumenos/PHCS
Managed Care, Inc.
MassMutual
Medicaid
Medicaid/ Texas Star
Medicaid/NHIC
Medical Control
Medical Control Inc
Medical Control/NetOne
Medical Eye Services
Medicare Rail Road
Mediplus
Mega Life & Health
Mercy Health Plans
Meritain Health
Meritain Health PHCS
Met Life//Wi
Met Life/Pennzoil
Met Life/Pittsburgh
Met Life/TU Electric
MetLife HMO
MetLife Med Supplement
MetLife Network/Austin
MetLife Vision Care
MetLife/Coca-Cola
MetLife/GM
MetLife/IL
MetLife/LTV
MetLife/Sears
MetLife/Shell/Tx
MetraHealth
MetraHealth Care/TX
MetraHealth/Albany
MetraHealth/Amer Air
MetraHealth/AT&T Wire
MetraHealth/Dallas
MetraHealth/Matteson
MetraHealth/MI
MetraHealth/NC
MetraHealth/NY
MetraHealth/RI
Metrahealth/Tampa
Metrahealth/Trav/Utah
MetraHealth/Umbrella
Metropolitan Life Ins Co
Metropolitan Life Ins.
Metropolitan Life/NY
Mid-West National Life Ins/PHCS
Missouri Pacific Ins,
MO., KS., TX. Railroad
Molina
Monumental Life
Monumental Life Ins.
Mutual Assurance Admin.
Mutual Assurance Administrators
Mutual of Omaha
Mutual of Omaha
Mutual of Omaha
Mutual Of Omaha-Addiso
Mutual Of Omaha-Dallas
Mutual Of Omaha/Exclus
Mutual Of Omaha/NTHN
Mutual Of Omaha/OK
Mutual Of Omaha/Omaha
MVP Health Care
MVPPO
NALC
NALC-Cigna
National Assoc. Letter Carriers
National Auto Sprinkle
National Benefit Corp
National Elevator
National Found. Life
National Foundation Life Ins. Co.
National Home Life Ins
National States Insurance
Natl Health Ins Co
NetOne Select
Network Adm., Inc. PPO
New England Care
New Era Life Ins
New Era Life Ins.
New ERA Life Insurance
New Era Life Insurance Companies
New York Life Ins
NHIC
Nippon Life Insurance
North American
North American Benefit
North American Benefit
North Texas HealthCare
North Texas Specialty Physicians
Northwestern Mutual
Novitas Solutions, Inc.
NPPN/NY
NYLCARE-HMO
NYLCare 65 **
NylCare 65 HealthplSW
NylCare 65 HMO (SPA)
NylCare Passport PPO
NylCare Passport PPOSW
NYLCARE PPO-DISD
NYLCARE/TUHP
NylCarePassport PPO/CA
Old Surety Life
Old Surety Life Insurance Company
One Health Plan
One Health Plan
One Health Plan
One Health Plan
OptiCare
Oxford Health Plans
P.F.L. Insurance
P5 e. Health Services, Inc.
Pacific Care
Pacific Health Adms.
Pacific Life & Annuity/AZ
Pacific Life/Annuity
PacifiCare Life/Health
PacifiCare Of Texas
Pacificare Senior Supplement Plan
PacifiCare/PHCS
PacifiCare/PHCS
PacifiCare/SPA
Palmetto GBA Railroad Medicare
Pan American Life
PCA Health Plan(Austin
PCA Solutions/Fl.
PCA/HMO/SPA
PCS
Pennsylvania Life Insurance Co.
PHA Ins. Services
PHCO
PHCS
PHCS
PHCS Private Healthcare Systems
PHCS/ Kaiser Permanente Insurance Co.
PHCS/AZ
PHCS/CA
PHCS/Citizen's Managmt
PHCS/IL
PHCS/IL
PHCS/Mercer Administration
PHCS/MO
PHCS/MO
PHCS/NC
PHCS/ReliaStar
PHCS/Trustmark
PHCS/TX
Philadelphia American Life
PHL(PHCS)
Phoenix Group Services
Phoenix Home Life/PHCS
Phoenix Mutual Life In
Physicians Mut Ins
Physicians Mutual
Physicians Mutual
Physicians Mutual
Physicians Mutual Ins.
Pinnacle Claims Management
Pioneer Life
Pioneer Management
Plano ISD
PM Group
PM Group
Pollocka Paper Distributors
Preferred Care
Preferred Care
Preferred Plan
Premier Benefits
Premier Medicare Sup.
Premier(PHCS)
Principal Financial Group
Principal Financial Grp/CO
Principal Health-IL
Principal Life Ins Co
Principal Life Ins. Co
Principal Life Insurance Co
Private Healthcare Systems
Pro-Net
Pro America
Pro America Network
Protective Insurance
Provident (Affordable)
Provident American Life
Provident American Life and Health Ins.
Provident Life & Acc
Provident Life & Acci
Provident/Chattanooga
Prudential-Health PPO
Prudential-PPO/CA
Prudential-PruNetwork
Prudential Group Healt
Prudential Health/HMO
Prudential Health/NJ
Prudential HealthCare
Prudential HMO/CUSTOM
Prudential Ins. Co/NY
Prudential Ins./IL
Prudential Ins./N.J.
Prudential Ins./Tx.
Prudential Ins/Anuity
Prudential Insurace Co of America
Prudential Network/CA
Prudential POS/HMO
Prudential/AT&T/Mo.
Prudential/AT&T/OH
Prudential/ATT/Fl.
PRUDENTIAL/ATT/NJ
Prudential/Care 90's
Prudential/CC/Mo
Prudential/Coca Cola
Prudential/Fl
Prudential/Glidden
Prudential/IBM
Prudential/S.A.., Tx
Prudential/TMA
PruNetwork
PruNetwork/Lucent
Pyramid Life Ins. Co.
Pyramid Life Insurance
Qual Choice
Railroad/Medicare
Reagit Ins./Affordable
Religious Comprehensive Trust
Reserve National Ins.
Reserve National Insurance
Retiree Medical Insurance
RH Admin. Inc., SPDDS
Risk Management
Rockwell, Claims Dept.
Royal Neighbors Of America
Rscko
Rural Carrier Benefit
SAG- Producers Health Plan
Samba
Samba
SAMBA
Scranton Ins
Secure Horiz/Pacifcare
Secure Horizons
Secure Horizons
Secure Horizons
Secure Horizons Direct
Secure Horizons/MMU
Secure Horizons/SPA
SecureHorizons
SecureHorizons/Medicare supplement
Senior Dimensions
Senior Health Service Center
Sentry Insurance
Shaw Medical/Acordia/PHCS
Sheet Metal Workers FU
Sierra Health & Life
Sierra Health and Life
Sierra/Olympic Health Mgmt
Sim USA
SKF USA Inc./ The loomis co.
Southern Benefits Con
Southwest Preferred
Southwest Service Life Insurance Company
Southwestern Financial
Southwire Company
SPA/DISD Claims
SPA/Mutual Of Omaha
Special Insurance Services
St.John's Claims Administration
Standar Life and Accident Insurance Comp
Standard Financial
Standard Life & Acc
Standard Life & Accident Insurance
Standard Life & Casualty
Standard Life and Accident
Standard Life Insurance
Starmark/PHCS
State Bar Of Texas
State Farm Health Ins
State Farm Health Ins/CO
State Farm Health Insurance
State Farm Health Insurance
State Farm Health Insurance
State Farm Ins
State Farm Ins.
State Farm Ins./Texas
State Farm Ins/IA
State Mutal Insurance Co.
State Mutual Ins. Co.
Sterling Ins.
Sterling Medicare Select
Sterling Plumbing Grp
Sterling Premier
Stonebridge Life
Superior Health Plan
T & C/ProAmerica
T.A.S.B. Insurance
TeamCare (PHCS)
Teamsters Benefit Trust
Texan Plus
Texas Dental Assoc.
Texas Health Choice
Texas Medical Association Ins
Texas Pipe Trades
Texas True Choice
Texas True Choice
The Covenant Group
The Empire Plan
The Goodyear Tire & Rubber Co
The Grotenhuis Group
The Guardian/PHCS/AZ
The Guardian/PHCS/WA
The Guardian/PHCS/WI
The Guardian/WI
The Mail Handlers Benefit Plan
The Mail Handlers Benefit Plan
The Mega Life Insurance Company PHCS
The Principal
The Principal
The Principal (IA)
The Principal Group
The Principal HMO-3426
The Principal Life Ins
The Prudential/FL
The Prudential/NJ
The Pyramid Life Insurance Company
The Reliable Insuranc
The Senior Health Plan
The Travelers/CT
The UCIP Program
The United States Life Ins.
Third Party Ad.Garland
Third Party Adm./Arlin
Thrivent Finicial
TI/Affordable
Time Insurance
Time Insurance Co
TML Group
TML IEBP
Total Plan Services
Total Plan Services Inc./ PHCS
Tower Life Insurance Company
TPA
TPA, Inc.
TPA/United Health
TPA/United Health/IL
TPA/UnitedHealthCar AZ
TPA/UnitedHealthCar TN
Transamerica Life Insurance Company
Travelers
Travelers Ins
Travelers Ins./Albany
Travelers Insurance Co
TRICARE
Tricare For Life
Trigon BCBS Of Va.
Trustmark
Trustmark
TrustMark
Trustmark/PHCS
Tucker & Clark(PPO)
Tx Life Accident Healt
U.C.T. Travelers
UFM International
UICI Administrators
UMR
UMR
UMR
UMR
Unicare
Unicare
Unicare
Unicare
UniCare
UniCare
UniCare
UNICARE-Classic/Baylor
UniCare-Medicare Supp
UNICARE-VAN NUYS
Unicare Classic
UNICARE Life & Health
Unicare/CT
Unicare/IL
UniCare/IL
UniCare/Ma
UniCare/MA
Unicare/MI
UNICARE/OXNARD
Unicare/TX
Unicare/Wellpoint NetW
Union Bankers
Union Fidelity Life
Union Fidelity Med. S
Union Security Ins. Co. /PHCS
United American Ins
United American Insurance
United Benefit Life
United Commercial Travelers
United Health Care
United Health Integrated Services
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare
United Healthcare/GA
United of Omaha Life Insurance Co.
United Teacher Associates
United Teachers Associates
United Teachers Associates Insurance Company
Universal Health Care Insurance
USAA Life Insurance
UTA
Wausau Insurance
Web TPA
WellCare
Western & Southern
Insurance ID:
Insurance Policy Group:
Not Primary on Account:
Not Primary
Primary on Account
Name:
Last, First MI
Relationship to Insured:
Spouse
Child
Other
Sex:
Male
Female
Address:
City:
State:
Zip:
Phone Number:
Birthday:
SSN:
Employer/School:
Medical History
Medical History
#1
Diabetes
HBP
Heart disease
Cancer
Arthritis
Lupus
Kidney
Thyroid
Back Problems
#2
Diabetes
HBP
Heart disease
Cancer
Arthritis
Lupus
Kidney
Thyroid
Back Problems
#3
Athritis
Diabetes
HBP
Heart Disease
Cancer
Lupus
Kidney Disease
Thyroid Disease
Back Problems
#4
Diabetes
HBP
Heart Disease
Cancer
Arthritis
Lupus
Kidney
Thyroid
Back Problems
#5
Diabetes
HBP
Heart Disease
Cancer
Arthritis
Lupus
Kidney
Thyroid Disease
Back Problems
#6
Diabetes
HBP
Heart Disease
Cancer
Arthritis
Lupus
Kidney Disease
Thyroid
Back Problems
Injuries, Surgeries, Hospitalization
Pregnant Or Nursing:
No
Yes
Unsure
Recent Tetanus Shot:
Yes
No
Notes:
Primary Care Physcian:
Last Visit:
1 week
1 month
3 months
6 months
1 year
2 years
Reason For Visit:
Check up
Annual
No current meds
No Known Drug Allergies
Over The Counter:
None
Asprin
Acetomenophin
Ibuprofen
Vitamins:
Family Medical History
#1
#2
#3
#4
#5
#6
Additional Family Medical History
Hobbies:
Astronomy
Art
Baseball
Boating
Basketball
Cooking
Crafts
Dancing
Diving
Football
Fishing
Golf
Gardening
Horseback Riding
Hunting
Models
Needlepoint
None
Painting
Photography
Piano
Reading
Running
Roller Blading
Softball
Sewing
Skiing
Soccer
Swimming
Tennis
Video Games
Woodworking
Smoking Status:
Never Smoker
Current every day smoker
Current some day smoker
Former smoker
Smoker, currernt status unknown
Unknown if ever smoked
Type:
None
Cigarettes
Chewing Tobacco
Other Tobacco Use
How Long:
Alcohol:
No
Yes
Occasionally
Socially
Type:
None
Beer
Wine
Hard Liquor
How Long:
Illegal Drugs:
No
Yes
Type:
How Long:
STD:
None
Gonorrhea
Syphilis
Hepatitis
HIV
TB
HIPAA:
Signature On File
**The Patient assumes responsibility for changes to the account. Services not covered or
paid by the insurance company will be the responsibility of the patient.
I hereby authorize the release of any medical information necessary to process my claim.
I also request payment of benefits to either myself or the party who accepts assignment.**
Medication List
RoS
GENERAL: Fever, weight loss, weight gain, fatigue?
None
Negative
EAR, NOSE, THROAT: Allergies, Sinus, Cough, Dry Mouth / Throat
None
Allergies
Sinus Problems
Chronic Cough
Dry Throat / Mouth
Hard of Hearing
CARDIOVASCULAR: High BP, Heart Surgery, Vascular Disease
None
Vascular Disease
HBP
Heart Surgery
RESPIRATORY: Asthma, Bronchitis, Emphysema, COPD
None
Asthma
Bronchitis
Emphysema
COPD
GENITAL, KIDNEY, BLADDER: Kidney Stones, Frequent Urination, impotence
None
painful urination
frequent urination
impotence
yellow jaundice
MUSCLES, BONES, JOINTS: Arthritis, Joint Pains, Head or Neck Injury
None
joint pain
stiffness
swelling
cramps
arthritis
SKIN: growths, rashes, acne
None
pimples, warts
growths
rash
NEUROLOGICAL: Headaches, migraines, seizures
None
numbness, paralysis
headache
seizures
migraines
PSYCHIATRIC: Depression, Anxiety, Insomnia
None
anxiety
depression
insomnia
ENDORCRINE: Thyroid, Diabetes
None
diabetes
hypothyroid
hyperthoyroid
BLOOD/LYMPH: Anemia, cholesterol, bleeding problems
None
bleeding
cholestrolemia
anemia
ALLERGIC / IMMUNOLOGIC: Seasonal Allergies, Rheumatoid, AIDS, Allergy Shots, Lupus
None
sneezing
swelling
redness
itching
hives
lupus
GASTROINTESTINAL: Diarrhea, Constipation, Ulcer, Reflux
None
Diarrhea
Constipation
Ulcer
Acid Reflux
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