Patient Information Updates

Please fill out this form if you are updating any information for your child.

Email
This field is for validation purposes and should be left unchanged.
Patient Information
Patient Name*
First Middle Last
Patient Date of Birth*
MM slash DD slash YYYY
Legal Guardian*
Email*
Update Addresses and Phone Number
If you have moved, need your mail delivered to a different address and/or have a new phone number for us to contact you at, please update your new information below.
Phone
Update Patient Address
If you have moved please update your address.

Street Address Address Line 2 City State ZIP Code
Update Patient Mailing Address
If different than address above

Street Address Address Line 2 City State ZIP Code
Update Patient Payment/Insurance Information
If your insurance has changed, please fill out your new insurance information below and call our office at 336-375-2240 and speak to billing for updated benefit information as it is subject to change from your current rate. If your child has Medicaid, please put their Medicaid number and select their Managed Care Organization (MCO) as well as adding the subscriber ID for their chosen organization.
Medicaid
- Medicaid
- Health Choice
- United Health Care Community Health Plan
- Carolina Complete of NC
- Healthy Blue of NC
- Amerihealth Caritas of NC
- Vaya
- Trillium
Medicaid Number
Health Choice Number
UHC Number
Carolina Complete Number
Healthy Blue Number
Amerihealth Caritas Number
Vaya Number
Trillium Number
Update Primary Health Insurance
This insurance will be billed first if you have Medicaid
Insurance Company Name
Insurance Company Phone
Patient ID Number
Policy/Group Number
Insured's Name
First Middle Last
Insured's Date of Birth
MM slash DD slash YYYY
Insured's SSN
If you are updating your insurance information, please provide a picture of the front and back of you card below:
Front of Card
Max. file size: 512 MB.
Back of Card
Max. file size: 512 MB.
This field is hidden when viewing the form
Untitled

Please fill out this form if you are updating any information for your child.

Patient Information

Update Addresses and Phone Number

Update Patient Payment/Insurance Information

Update Primary Health Insurance

If you are updating your insurance information, please provide a picture of the front and back of you card below:

Newsletter

Let's Keep Talking

Helpful Links