Provider:
Dr. Arthur Castelbaum
Dr. Martin Freedman
Dr. Jackie Gutmann
Dr. Allison Lange
Dr. William Schlaff
Dr. Jeffrey Thorne
Insurance Name:
Insurance Type:
PPO
HMO
Insurance ID #:
Subscriber
Subscriber Date of Birth
Insurance Phone #:
Do you have a FSA/HSA/HRA?
FSA
HSA
HRA
None
Please upload a photo of the following: The front/back of your insurance card and if you have a separate pharmacy benefit card the front/back of it as well.
If you see an RXBIN on your insurance card that is your pharmacy benefit information and you will not have a separate card. If you do not have that or a separate card it is likely in your insurance plan and you do not need to provide a photo.
Add files
Drop files anywhere to add
Submit