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Payor Name	Payor Plan	Payor Address	Electronic Payor ID
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Address Type

Payor ^*

Payor Code

Electronic Payor ID

Policy ID / Eligibility ID

Plan Name

Plan ID

Group Name

Group ID

Payor Rank

Copay

Co-Insurance%

Deductible

Address Type

Address Permissions

Address Line 1

Address Line 2

City

State

County

Postal Code

Primary

Effective Date

Expiration Date

Payor Eligibility Expiration Reason

Enter Other Payor Eligibility Expiration Reason

Add / Retro Date

Policy Holder

Policy Holder Relationship

Does the Policy Holder's Name match the insurance card?

Policy Holder First Name

Policy Holder Middle Name

Policy Holder Last Name

Suffix

POLICY HOLDER’S EMPLOYER

Does the Client (Contact) match the insurance card?

Billing Contact First Name ^*

Billing Contact Middle Name

Billing Contact Last Name ^*

Billing Contact Suffix

Additional information: Co-insurance,co-pay,Deductible and Percentage3000 characters remaining

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Payor	Group Name	Plan Name	Policy Holder	Effeactive Date	Expiration Date	Eligibility
Aetna	Group	Health Plan	Self	02/12/2016	02/12/2017