Person submitting inquiry  Patient Employer Employee Provider Other      Relationship to patient  Self Employer n/a Parent Spouse Guardian Other

Your Contact Information  (who should we send our results to regarding your claim inquiry?)

Name*

Business Name

Day Phone*

Fax

Mailing Address

State

Best way to contact you

Email Fax Day phone Night phone Mail

Plan Information

Employer Name*

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Medical Group #*

RX Group #

Member ID #*

Member ID* (confirmation)

Patient Number

Employee Information (name the plan is under)

First Name *

Last Name *

Middle Initial

Patient Information

Who received services? Employee   Other

If other is selected please complete patient section.

If Employee is selected please go to employee section below

First Name*

SS Number*

Last Name*

Birth Date*

Claim Information

Type of Inquiry

Claim Status Request copy of explanation of benefits Deductible status other-please describe in details below

1st Inquiry?

Yes    No

Date of Service

Type of Service

Office Visit Dental Lab and X-Ray Hospital Services Chiropractor Physical therapy Mental Health Surgical other-please describe in detail section below Prescription

Amount Billed 

Place of Service

Location

Street

Zip

Provider Name

Dr. Name

DETAILS              Please provide as much detail as possible regarding your inquiry.