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Patient Information
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Insurance Information
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If we are unable to confirm your insurance coverage or you are a self pay, a Patient Financial Advocate may contact you to confirm your information and discuss your options.

You may be asked to sign a financial liability form upon check-in for your visit if we are unable to confirm your insurance, secure an authorization or determine your financial responsibility

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Error: First name is required.
Error: Middle name is required.
Error: Last name is required.
Error: Name contains invalid characters.
Error: Spouse's last name is required.
Error: Spouse's last name first is required.
Error: Last name prefix is required.
Error: Spouse's last name prefix is required.
Error: Name suffix is required.
Error: Given name initials are required.
Error: Date of birth is required.
Error: Date of birth is invalid.
Error: Date of birth must be in the past.
Error: Legal sex is required.
Error: Race is required.
Error: Ethnicity is required.
Error: Preferred Language is required.
Error: Email address is required.
Error: Email address is invalid.
Error: Home phone is required.
Error: Phone number is invalid.
Error: Mobile phone is required.
Error: Phone number is invalid.
Error: Work phone is required.
Error: Phone number is invalid.
Error: Address is required.
Error: City is required.
Error: County is required.
Error: Please enter a county.
Error: District is required.
Error: Please enter a district.
Error: House number is required.
Error: State is required.
Error: Please enter a state.
Error: ZIP code is required.
Error: Zip code is invalid.
Error: Country is required.
Error: Please enter a country.
Error: Social Security number is required.
Error: Social Security number is invalid. The correct format is ###-##-####.
Error: Social Security number is required.
Error: Insurance is required.
Error: Insurance name is required.
Error: Member ID is required.
Error: Subscriber ID is required.
Error: Subscriber name is required.
Error: Subscriber date of birth is required.
Error: Subscriber date of birth is invalid.
Error: Subscriber date of birth must be in the past.
Error: Group number is required.
Error: Must be exactly 4 characters.
Error: Cannot exceed 18 characters
Error: Cannot exceed 20 characters
Error: Cannot exceed 25 characters
Error: Cannot exceed 40 characters
Error: Cannot exceed 50 characters
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Error: That MyChart ID is not available
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Error: The retyped password doesn't match the original.
Error: Your MyChart ID must be between @MYCHART@MINLEN@ and @MYCHART@MAXLEN@ characters.
Error: Your MyChart ID must have at least 3 characters.
Error: Your MyChart ID cannot contain any spaces or symbols other than a period (.), hyphen (-), underscore (_), or the at symbol (@).
Error: That MyChart ID is in use already.
Error: That username is not available.
Error: Your password must contain at least one letter and one number.
Error: Invalid password. Please enter a different password.
Error: Your password must have at least 2 characters.
Error: Your password must be between @MYCHART@MINLEN@ and @MYCHART@MAXLEN@ characters.
Error: Your password must be different than your username.
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