Claim Request Form

Your Information Name:
Phone:
Fax:
E-mail:
Group Name:
Group Number:

Service Information Date of Service:

Provider's Name:
Patient's Name:
Patient's ID#:

More Information My claim was denied.

Fax a copy of your explanation of benefits or doctor's bill to us for review or Call for explanation and advice.

My doctor hasn't received a response from my insurance on a submitted claim.

Call Member Services to see if the claim was received. If not, ask your doctor to resubmit the claim.

Please get back to me on the following claims issue:

Attention

There were some problems with the information you have submitted. Listed below are the fields that need attention.