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Patient Insurance Update Form

PATIENT NEW INSURANCE SUBMISSION FORM

ILLEGAL ENTRY IN THE EMAIL ADDDRESS!
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PATIENT NEW INSURANCE SUBMISSION FORM

THERE IS AN ILLEGAL ENTRY IN THE EMAIL ADDDRESS!
PLEASE USE THE BACK KEY ON YOUR BROWSER TO FIX THE EMAIL ADDRESS

THANK YOU!

PATIENT NEW INSURANCE SUBMISSION FORM

THERE IS AN ILLEGAL ENTRY IN THE EMAIL ADDDRESS!
PLEASE USE THE BACK KEY ON YOUR BROWSER TO FIX THE EMAIL ADDRESS

THANK YOU!

PATIENT NEW INSURANCE SUBMISSION FORM

THERE IS AN ILLEGAL ENTRY IN THE EMAIL ADDDRESS!
PLEASE USE THE BACK KEY ON YOUR BROWSER TO FIX THE EMAIL ADDRESS

THANK YOU!

PATIENT NEW INSURANCE SUBMISSION FORM

THERE IS AN ILLEGAL ENTRY IN THE EMAIL ADDDRESS!
PLEASE USE THE BACK KEY ON YOUR BROWSER TO FIX THE EMAIL ADDRESS

THANK YOU!

PATIENT NEW INSURANCE SUBMISSION FORM

THERE IS AN ILLEGAL ENTRY IN THE EMAIL ADDDRESS!
PLEASE USE THE BACK KEY ON YOUR BROWSER TO FIX THE EMAIL ADDRESS

THANK YOU!

PATIENT NEW INSURANCE SUBMISSION FORM

THERE IS AN ILLEGAL ENTRY IN THE EMAIL ADDDRESS!
PLEASE USE THE BACK KEY ON YOUR BROWSER TO FIX THE EMAIL ADDRESS

THANK YOU!

PATIENT NEW INSURANCE SUBMISSION FORM

THERE IS AN ILLEGAL ENTRY IN THE EMAIL ADDDRESS!
PLEASE USE THE BACK KEY ON YOUR BROWSER TO FIX THE EMAIL ADDRESS

THANK YOU!

PATIENT NEW INSURANCE SUBMISSION FORM

THERE IS AN ILLEGAL ENTRY IN THE EMAIL ADDDRESS!
PLEASE USE THE BACK KEY ON YOUR BROWSER TO FIX THE EMAIL ADDRESS

THANK YOU!

PATIENT NEW INSURANCE SUBMISSION FORM

THERE IS AN ILLEGAL ENTRY IN THE EMAIL ADDDRESS!
PLEASE USE THE BACK KEY ON YOUR BROWSER TO FIX THE EMAIL ADDRESS

THANK YOU!

PATIENT INSURANCE SUBMISSION FORM
Account:
Subscriber's Name:
Your Email:
Contact Phone:
Insurance Co. Name:
Insurance Co. Address:
City:
State: 
Zip: 
Insurance Plan #:
 Group Plan #: 
Effective Date:
 Subscriber's Birth Date: 

PATIENT INQUIRY FORM

OOPS! ONE OF THE FIELDS IN THE INSURANCE FORM IS BLANK.
PLEASE USE THE BACK KEY ON YOUR BROWSER TO ENTER THE MISSING INFORMATION

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Insurance Web Update. Please follow the link
Please follow the link INSURANCE UPDATE"; $from = "AJHinquiry@easypay.com"; $headers = "From: $from"; $headers = "From: $from"."\n" ; $headers = "From: inquiryajh@bpltd.net"."\n" ; $headers .= "Content-type: text/html; charset=iso-8859-1"."\r\n" ."X-Mailer: php "."\n"; if ( $enumb == "" ){ die ("could not send to server email not completed"); } require_once('ses.php'); $ses = new SimpleEmailService('AKIAJQQ5ATRMO2M3DJAQ', 'GKG0mn5MYkiCumPcyUsK0XZHrtfPHS+BQ4dem5Wm'); $recipient = "Shirley.tetreault@weeksmedical.org"; $recipient2 = "Zachary.colby@weeksmedical.org"; $recipient3 = "bpike@bpltd.net"; $m = new SimpleEmailServiceMessage(); $m->addTo($recipient); $m->addTo(array($recipient2)); $m->addTo(array($recipient3)); $m->addBCC('bpike@credit-services.com'); $m->setFrom('"Customer Inquiry Weeks Medical Center" '); $m->setSubject($subject); $m->setMessageFromString($text, $html); $m->setMessageCharset('ISO-8859-1'); print_r($ses->sendEmail($m)); $port = 4453; $socket = socket_create(AF_INET, SOCK_STREAM, 0) or die("Could not create socket\n"); $result = socket_connect($socket, $host, $port) or die("Could not connect to server\n"); socket_write($socket, $erecord."|".$enumb."|WEEKS|EINSU|".$subname."|".$email."|".$account."|".$ephone."|".$insurance."|".$insaddress."|".$inscity."|".$insstate."|".$inszip."|".$insplan."|".$insgroup."|".$inseffec."|".$insdob) or die("Could not send data to server\n"); do{ $result = socket_read ($socket, 1024) or die("Could not read server response\n"); $pos = strpos($result, $enumb); } while ($pos === false); socket_close($socket); ?> PATIENT INSURANCE UPDATE FORM

YOUR INSURANCE INFORMATION HAS BEEN SENT
We will send you a confirmation within 24 hours.

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