Blue Shield / Anthem Blue Cross

Insurance & Billing Form

Name

First Name

Last Name

Date of Birth

Insurance Plan Name

Medical Record Number

Please send me an invitation to sign Intake Paperwork

If you want to get started with intake paperwork, we will send you an invitation to register an account where you will be able to submit all paperwork.

For online payments for services, please scan the QR code
or click on the PAYPAL PAYMENTS button below to be led
to our Paypal System. Please indicate the date
and/or service you are paying for.

Paypal Payments

Anthem Blue Cross & Blue Shield of California

Blue Shield / Anthem Blue Cross

For online payments for services, please scan the QR code or click on the PAYPAL PAYMENTS button below to be led to our Paypal System. Please indicate the date and/or service you are paying for.

For online payments for services, please scan the QR code
or click on the PAYPAL PAYMENTS button below to be led
to our Paypal System. Please indicate the date
and/or service you are paying for.