Rapid Patient Benefits Check - Lakeside Medical Group

Lakeside Medical Rapid Member Benefits Verification

Benefits Check- Use this form to quickly verify/register a Lakeside Medical Group member:

Provider Name

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Please provide the name of the medical services provider

Provider E-mail(*)

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Is an Emergency?(*)

YesNo

Please check Yes or No

Emergency Description

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Patient Name

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Please provide the patients full name as is displayed on the insurance card

Date of Birth

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Please provide the Subscribers Date of Birth

Policy Number

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or Member ID

Insurance Carrier

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Please provide the Insurance Carriers Name and phone number

Insurance Card Front

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(Front of Card) For your convenience and faster processing, please scan or take a picture of the front of your insurance card and upload it here.

Insurance Card Back

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(Back of Card) Please scan or take a picture of the back of your insurance card and upload it here.

Identification Card Front (Gov)

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(Front of Card) For your convenience and faster processing, please scan or take a picture of the front of your insurance card and upload it here.

Identification Card Back

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(Back of Card) Please scan or take a picture of the back of your insurance card and upload it here.

Are you a Human?(*)

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