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Patient Information
Patient's First Name
Patient's Last Name
Mobile # to Send Confirmation
Reason for Referral
Medical Insurance
Aetna
Amerigroup
Amerivantage
Austin Regional Clinic
Austin Regional Independent Associates (ARIA)
Averde Health
Avmed
Beech Street
Blue Cross Blue Shield
Brookshire Brothers Healthplan
Centene
Cigna
Covenant Management Solutions
Coventry
DARS
Fidelis Secure Care
First Health
FirstCare
Galaxy Health Network
HealthNet
HealthSmart Preferred Care
Humana
Independent Medical Systems
Magellan Health
MultiPlan
Prime Health Services, Inc.
Private Healthcare Systems (PHCS)
Scott & White Health Plan
Seton Health Plan
Shannon Health Plan
SmartHealth
UnitedHealthcare
USA Health Network
Other
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What's the Patient's Insurance?
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Referring Partner
Name of Physician or Organization
Physicians Premier ER - Bulverde
Emergency Room
Open 24 Hours
20475 Highway 46, Suite 100
Spring Branch, TX 78070
(830) 438-6911
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