Sample Health Insurance ID Card - Welcome to FAIR Health

1 2 3 4 5 7 8 9 10 11 12 Front of Card Back of Card 6 13 Sample Health Insurance ID Card Sample Health Insurance ID Card: Key ID Number Name Number Care Provider (PCP) Name and Phone Number Type for Visits to Primary Care Provider for Specialty Care for Emergency and Urgent Care Drug plan Information plan Website Address Deductible and Coinsurance (OON) Deductible and Coinsurance Contact Information

Prescription Drug Plan Information 10. Health Plan Website Address 11. In-Network Deductible and Coinsurance 12. Out-of-Network (OON) Deductible and Coinsurance 13. Plan Contact Information . USA Insurance Company 5678 1234-A Mary A. Doe GRP: 2424-78787 WXZ PCP: Dr. Michael Jones PCP Telephone: (212) 234-5678 PPO SPC URGENT Rx Co-Pay:

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