Claims Help
When submitting claims information, please complete all fields as accurate as possible. Our staff may require a HIPAA document allowing our staff to access claims information on your behalf.If so, we will send them to you via e-mail. We look forward to helping you.
Medical form with stethoscope
Primary insured information (Employee):
Primary insured e-mail:
Employer name (Company):
Patient name:
Patient ID number:
Relationship to  primary insured:
Date of Service:
Upload your bill or Explanation of Benefits:
Upload File

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