{"id":1014,"date":"2022-09-29T04:07:37","date_gmt":"2022-09-29T04:07:37","guid":{"rendered":"https:\/\/cimamd.com\/?page_id=1014"},"modified":"2022-09-29T04:07:37","modified_gmt":"2022-09-29T04:07:37","slug":"insurance-information","status":"publish","type":"page","link":"https:\/\/cimamd.com\/zh\/appointment\/insurance-information\/","title":{"rendered":"Insurance Information"},"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-2\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><\/div><\/div><\/div><div class=\"wpb_column vc_column_container vc_col-sm-8\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f972-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"972\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form 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data-name=\"primary-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"primary-name\" \/><\/span> <\/label>\n<\/p>\n<p><label> Date of Birth of primary insurer<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dob-primary\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"dob-primary\" \/><\/span> <\/label>\n<\/p>\n<p><label> Relationship with primary insurer<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"primary-relationship\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"primary-relationship\" \/><\/span> <\/label>\n<\/p>\n<p><label> ID#<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"id-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"id-number\" \/><\/span> <\/label>\n<\/p>\n<p><label> Group #\u200b\u200b<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"group-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"group-number\" \/><\/span> <\/label>\n<\/p>\n<p><label> Plan Name if applicable<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"plan-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"plan-name\" \/><\/span> <\/label>\n<\/p>\n<p><label> Deductible<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"deductible\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"deductible\" \/><\/span> <\/label>\n<\/p>\n<p><label> Copay information if applicable<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"copay\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"copay\" \/><\/span> <\/label>\n<\/p>\n<p><label> For Tricare DBN<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tricare-dbn\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"tricare-dbn\" \/><\/span> <\/label>\n<\/p>\n<p><label> Insurance Card Picture Front (jpg or pdf 1mb or less)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"insurance-card-front\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpg,.jpeg,.pdf\" aria-invalid=\"false\" type=\"file\" name=\"insurance-card-front\" \/><\/span> <\/label>\n<\/p>\n<p><label> Insurance Card Picture Back (jpg or pdf 1mb or less)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"insurance-card-back\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpg,.jpeg,.pdf\" aria-invalid=\"false\" type=\"file\" name=\"insurance-card-back\" \/><\/span> <\/label>\n<\/p>\n<p><label> Driver's License Front (jpg or pdf 1mb or less)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"license-front\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpg,.jpeg,.pdf\" aria-invalid=\"false\" type=\"file\" name=\"license-front\" \/><\/span> <\/label>\n<\/p>\n<p><label> Driver's License Back (jpg or pdf 1mb or less)<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"license-back\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file\" accept=\".jpg,.jpeg,.pdf\" aria-invalid=\"false\" type=\"file\" name=\"license-back\" \/><\/span> <\/label>\n<\/p>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"\u63d0\u4ea4\" \/>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<input type=\"hidden\" name=\"trp-form-language\" value=\"zh\"\/><\/form>\n<\/div>\n<\/div><\/div><\/div><div class=\"wpb_column vc_column_container vc_col-sm-2\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><\/div><\/div><\/div><\/div>\n<\/div>","protected":false},"excerpt":{"rendered":"<p>First Name Family Name Email Date of Birth Name of primary insurer if not self Date of Birth of primary insurer Relationship with primary insurer ID# Group #\u200b\u200b Plan Name if applicable Deductible Copay information if applicable For Tricare DBN Insurance Card Picture Front (jpg or pdf 1mb or less) Insurance Card Picture Back (jpg&hellip;<\/p>","protected":false},"author":1,"featured_media":0,"parent":43,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-1014","page","type-page","status-publish","hentry","description-off"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v24.1 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ 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