Submit Insurance Information to PCB

First, please select which type of insurance information you’d like to submit.

Name*
First Last
Phone*
Email
Document Uploads
Have a document to share with us? (e.g.: Insurance Card or Explanation of Benefits (EOB)) Attach it here.
Max. file size: 50 MB.
Patient Information
Patient Name
PCB Account Number
Hospital Name/Dr. Name
Primary Insurance Coverage Information
Carrier Name*
Street
City
State
Postal Code
Phone
Policy Holder's Name*
Identification No.*
Employer Name
Effective Date
MM slash DD slash YYYY
Termination Date
MM slash DD slash YYYY
Secondary Coverage (optional)
Carrier Name
Street
City
State
Postal Code
Phone
Policy Holder's Name
Identification No.
Employer Name
Effective Date
MM slash DD slash YYYY
Termination Date
MM slash DD slash YYYY
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

Name*
First Last
Phone*
Email
Document Uploads
Have a document to share with us? (e.g.: Insurance Card or Explanation of Benefits (EOB)) Attach it here.
Max. file size: 50 MB.
Patient Information
Patient Name
PCB Account Number
Hospital Name/Dr. Name
Insurance Coverage Information
Carrier Name*
Street
City
State
Postal Code
Phone
Policy Holder's Name*
Claim Number*
Date of Accident
MM slash DD slash YYYY
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.

Name*
First Last
Phone*
Email
Document Uploads
Have a document to share with us? (e.g.: Insurance Card or Explanation of Benefits (EOB)) Attach it here.
Max. file size: 50 MB.
Patient Information
Patient Name
PCB Account Number
Hospital Name/Dr. Name
Insurance Coverage Information
Carrier Name*
Street
City
State
Postal Code
Phone
Employer's Name*
Employer's Phone
Claim Number*
Date of Accident
MM slash DD slash YYYY
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.

Name*
First Last
Phone*
Email
Document Uploads
Have a document to share with us? (e.g.: Insurance Card or Explanation of Benefits (EOB)) Attach it here.
Max. file size: 50 MB.
Patient Information
Patient Name*
PCB Account Number
Hospital Name/Dr. Name
Medicare Information
Medicare ID Number*
Part A Effective Date
MM slash DD slash YYYY
Part B Effective Date
MM slash DD slash YYYY
If you are a member of Medicare HMO, please provide the following information:
HMO Name
Street
City
State
Postal Code
Phone
Identification No.
Employer Name
Effective Date
MM slash DD slash YYYY
Termination Date
MM slash DD slash YYYY
If you have insurance coverage supplemental to medicare that will pickup costs after Medicare's payment, please provide that information as supplemental insurance information below:
Carrier Name
Street
City
State
Postal Code
Phone
Policy Holder's Name
Identification No.
Effective Date
MM slash DD slash YYYY
Termination Date
MM slash DD slash YYYY
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

Name*
First Last
Phone*
Email
Document Uploads
Have a document to share with us? (e.g.: Insurance Card or Explanation of Benefits (EOB)) Attach it here.
Max. file size: 50 MB.
Patient Information
Patient Name*
PCB Account Number
Hospital Name/Dr. Name
Medicaid Information
Medicaid ID Number*
Date of Birth*
MM slash DD slash YYYY
If you have Medicaid in a State other than New York, please provide the following Information:
Medicaid ID Number
Medicaid State
Effective Date
MM slash DD slash YYYY
Carrier Name
Street
City
State
Postal Code
Phone
Insured Name
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.