{"id":14082,"date":"2019-11-05T14:25:17","date_gmt":"2019-11-05T21:25:17","guid":{"rendered":"https:\/\/uewm.edu\/?page_id=14082"},"modified":"2021-02-09T19:55:24","modified_gmt":"2021-02-10T02:55:24","slug":"insurance-verification","status":"publish","type":"page","link":"https:\/\/uewm.edu\/ch\/insurance-verification","title":{"rendered":"Insurance Verification"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><div class=\"vc_row wpb_row vc_row-fluid\"><div class=\"wpb_column vc_column_container vc_col-sm-12\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\">\n\t<div class=\"wpb_text_column wpb_content_element\" >\n\t\t<div class=\"wpb_wrapper\">\n\t\t\t<h1>Insurance verification<\/h1>\n\n\t\t<\/div>\n\t<\/div>\n\n\t<div class=\"wpb_text_column wpb_content_element\" >\n\t\t<div class=\"wpb_wrapper\">\n\t\t\t<p><strong>We accept Private Insurance (PPO plans):<\/strong><\/p>\n<ul>\n<li>\u00a0\u00a0Anthem Blue Cross<\/li>\n<li>\u00a0\u00a0United Health Care<\/li>\n<li>\u00a0\u00a0Aetna<\/li>\n<li>\u00a0\u00a0Cigna<\/li>\n<li>\u00a0\u00a0Blue Shield (deposit required)<\/li>\n<li>\u00a0\u00a0Flexible spending account (FSA)<\/li>\n<li>\u00a0\u00a0Health savings account (HSA)<\/li>\n<li>\u00a0\u00a0Medi-Cal for eligible Patients*<br \/>* Worker\u2019s Compensation<br \/>* Personal Injury Insurance<\/li>\n<\/ul>\n<p><strong>Please fill out the form below for your insurance verification<\/strong><\/p>\n\n\t\t<\/div>\n\t<\/div>\n\n\t<div class=\"wpb_text_column wpb_content_element\" >\n\t\t<div class=\"wpb_wrapper\">\n\t\t\t\n\t\t<\/div>\n\t<\/div>\n<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-14996\"><form id=\"wpforms-form-14996\" class=\"wpforms-validate wpforms-form\" data-formid=\"14996\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/ch\/wp-json\/wp\/v2\/pages\/14082\" data-token=\"b548980a5fbf6a4fe4fae94e63268205\" data-token-time=\"1783209685\"><noscript class=\"wpforms-error-noscript\">\u8bf7\u5728\u6d4f\u89c8\u5668\u4e2d\u542f\u7528JavaScript\u6765\u5b8c\u6210\u6b64\u8868\u5355\u3002<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-14996-field_1-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-14996-field_1\">Employer&#039;s Name<\/label><input type=\"text\" id=\"wpforms-14996-field_1\" class=\"wpforms-field-medium\" name=\"wpforms[fields][1]\" ><\/div><div id=\"wpforms-14996-field_24-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"24\"><label class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-14996-field_24\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][24][first]\" required><label for=\"wpforms-14996-field_24\" class=\"wpforms-field-sublabel after\">\u524d\u4e00\u9875<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-14996-field_24-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][24][last]\" required><label for=\"wpforms-14996-field_24-last\" class=\"wpforms-field-sublabel after\">\u540e\u4e00\u9875<\/label><\/div><\/div><\/div><div id=\"wpforms-14996-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-14996-field_3\">Middle Initial<\/label><input type=\"text\" id=\"wpforms-14996-field_3\" class=\"wpforms-field-medium\" name=\"wpforms[fields][3]\" ><\/div><div id=\"wpforms-14996-field_5-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-14996-field_5\">Date of Birth <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-14996-field_5\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][5]\" required><\/div><div id=\"wpforms-14996-field_6-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"6\"><label class=\"wpforms-field-label\">Gender <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-14996-field_6\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-14996-field_6_1\" name=\"wpforms[fields][6]\" value=\"Male\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-14996-field_6_1\">Male<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-14996-field_6_2\" name=\"wpforms[fields][6]\" value=\"Female\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-14996-field_6_2\">Female<\/label><\/li><\/ul><\/div><div id=\"wpforms-14996-field_7-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-14996-field_7\">Phone Number<\/label><input type=\"text\" id=\"wpforms-14996-field_7\" class=\"wpforms-field-medium\" name=\"wpforms[fields][7]\" ><\/div><div id=\"wpforms-14996-field_8-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-14996-field_8\">Email<\/label><input type=\"text\" id=\"wpforms-14996-field_8\" class=\"wpforms-field-medium\" name=\"wpforms[fields][8]\" ><\/div><div id=\"wpforms-14996-field_10-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-14996-field_10\">Chief Complaint or Primary Diagnosis <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-14996-field_10\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][10]\" required><\/div><div id=\"wpforms-14996-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-14996-field_11\">Street Address <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-14996-field_11\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][11]\" required><\/div><div id=\"wpforms-14996-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-14996-field_12\">Street Address Line 2<\/label><input type=\"text\" id=\"wpforms-14996-field_12\" class=\"wpforms-field-medium\" name=\"wpforms[fields][12]\" ><\/div><div id=\"wpforms-14996-field_13-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-14996-field_13\">City <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-14996-field_13\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][13]\" required><\/div><div id=\"wpforms-14996-field_14-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-14996-field_14\">State <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-14996-field_14\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][14]\" required><\/div><div id=\"wpforms-14996-field_15-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-14996-field_15\">Zip Code<\/label><input type=\"text\" id=\"wpforms-14996-field_15\" class=\"wpforms-field-medium\" name=\"wpforms[fields][15]\" ><\/div><div id=\"wpforms-14996-field_16-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-14996-field_16\">Insurance Company Name<\/label><input type=\"text\" id=\"wpforms-14996-field_16\" class=\"wpforms-field-medium\" name=\"wpforms[fields][16]\" ><\/div><div id=\"wpforms-14996-field_17-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-14996-field_17\">Insurance Company Phone Number<\/label><input type=\"text\" id=\"wpforms-14996-field_17\" class=\"wpforms-field-medium\" name=\"wpforms[fields][17]\" ><\/div><div id=\"wpforms-14996-field_18-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-14996-field_18\">Policy Number \/ ID Number<\/label><input type=\"text\" id=\"wpforms-14996-field_18\" class=\"wpforms-field-medium\" name=\"wpforms[fields][18]\" ><\/div><div id=\"wpforms-14996-field_19-container\" class=\"wpforms-field wpforms-field-select\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-14996-field_19\">Relationship to Insured<\/label><select id=\"wpforms-14996-field_19\" class=\"wpforms-field-medium\" name=\"wpforms[fields][19]\"><option value=\"Self\"  class=\"choice-1 depth-1\"  >Self<\/option><option value=\"Spouse\"  class=\"choice-2 depth-1\"  >Spouse<\/option><option value=\"Child\"  class=\"choice-3 depth-1\"  >Child<\/option><option value=\"Other\"  class=\"choice-4 depth-1\"  >Other<\/option><\/select><\/div><div id=\"wpforms-14996-field_20-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-14996-field_20\">Group #<\/label><input type=\"text\" id=\"wpforms-14996-field_20\" class=\"wpforms-field-medium\" name=\"wpforms[fields][20]\" ><\/div><div id=\"wpforms-14996-field_21-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-14996-field_21\">Claim # if an Accident<\/label><input type=\"text\" id=\"wpforms-14996-field_21\" class=\"wpforms-field-medium\" name=\"wpforms[fields][21]\" ><\/div><div id=\"wpforms-14996-field_22-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-14996-field_22\">Date of Accident \/ Injury<\/label><input type=\"text\" id=\"wpforms-14996-field_22\" class=\"wpforms-field-medium\" name=\"wpforms[fields][22]\" ><\/div><div id=\"wpforms-14996-field_23-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-14996-field_23\">Leave a Comment<\/label><textarea id=\"wpforms-14996-field_23\" class=\"wpforms-field-medium\" name=\"wpforms[fields][23]\" ><\/textarea><\/div><div id=\"wpforms-14996-field_25-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"25\"><ul id=\"wpforms-14996-field_25\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-14996-field_25_1\" name=\"wpforms[fields][25][]\" value=\"Subscribe our newsletter\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-14996-field_25_1\">Subscribe our newsletter<\/label><\/li><\/ul><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-field wpforms-field-hp\"><label for=\"wpforms-14996-field-hp\" class=\"wpforms-field-label\">Name<\/label><input type=\"text\" name=\"wpforms[hp]\" id=\"wpforms-14996-field-hp\" class=\"wpforms-field-medium\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"14996\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/uewm.edu\/ch\/wp-json\/wp\/v2\/pages\/14082\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-14996\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><\/div><\/form><\/div>  <!-- .wpforms-container -->\n\t<div class=\"wpb_text_column wpb_content_element\" >\n\t\t<div class=\"wpb_wrapper\">\n\t\t\t<p>For more information, Please contact <a href=\"mailto:insu@uewm.edu\" target=\"_blank\" rel=\"noopener noreferrer\">insu@uewm.edu<\/a><\/p>\n\n\t\t<\/div>\n\t<\/div>\n<\/div><\/div><\/div><\/div>\n<\/div>","protected":false},"excerpt":{"rendered":"Insurance verification We accept Private Insurance (PPO plans): \u00a0\u00a0Anthem Blue Cross \u00a0\u00a0United Health Care \u00a0\u00a0Aetna \u00a0\u00a0Cigna \u00a0\u00a0Blue Shield (deposit required) \u00a0\u00a0Flexible spending account (FSA) \u00a0\u00a0Health savings account (HSA) \u00a0\u00a0Medi-Cal for eligible Patients** Worker\u2019s Compensation* Personal Injury Insurance Please fill out &hellip;","protected":false},"author":9,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"pmpro_default_level":"","rs_blank_template":"","rs_page_bg_color":"","slide_template_v7":"","_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-14082","page","type-page","status-publish","hentry","pmpro-has-access"],"_links":{"self":[{"href":"https:\/\/uewm.edu\/ch\/wp-json\/wp\/v2\/pages\/14082","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/uewm.edu\/ch\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/uewm.edu\/ch\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/uewm.edu\/ch\/wp-json\/wp\/v2\/users\/9"}],"replies":[{"embeddable":true,"href":"https:\/\/uewm.edu\/ch\/wp-json\/wp\/v2\/comments?post=14082"}],"version-history":[{"count":15,"href":"https:\/\/uewm.edu\/ch\/wp-json\/wp\/v2\/pages\/14082\/revisions"}],"predecessor-version":[{"id":14997,"href":"https:\/\/uewm.edu\/ch\/wp-json\/wp\/v2\/pages\/14082\/revisions\/14997"}],"wp:attachment":[{"href":"https:\/\/uewm.edu\/ch\/wp-json\/wp\/v2\/media?parent=14082"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}