Physicians Laboratory Online Bill Pay Online Insurance Submission

Phone (605) 322-7200

Insurance Information Request Form

Name: First* Middle Initial Last*
Account Number*
Date of Birth: Month* Day* Year*
Street*
City* State* Zip*

Primary Insurance Information

Insurance Company*
Policy Number* OR Member Number*
Group or Account Number*
Insurance Company Address*
Other Information

Secondary Insurance Information (If Applicable)

Insurance Company
Policy Number OR Member Number
Group or Account Number
Insurance Company Address
Other Information