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?(*)
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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