AssureCare - Member Inquiry

	Changing the Landscape of Healthcare Costs and Outcomes
New Directions In Healthcare	Greater Freedom of Choice - Substantial Savings

*Contact your employer to change dependant status, address changes or questions regarding COBRA.

Plan Information
Employer Name *required
Medical Group #		Click on card for more examples
RX Group #
Member ID # *required
Member ID # (confirmation)
Patient #
Patient Information
First Name		Last Name
Middle Initial		Soc Sec #
Employee Information (name the plan is under)
First Name *required		Last Name *required
Middle Initial
Contact Information (who should we contact regarding your inquiry?)
Name
Day Phone		Night Phone
Fax		E-mail
Preferred contact method:

Indicate services requested:
	Order ID Cards
	Request AssureCare Customer Service Representative to call
	General Inquiry
	Request Plan Coverage Information
	Request Provider Information
	Submit Deductible and Co-insurance Inquiries
DETAILS Please provide as much detail as possible regarding the service you requested.