Patient Services

 

Claim questions and processing

Account #                      This can be found in the upper right hand corner of your statement.

Patient Name             

Questions and comments

   

The following information, if not already given, will help process your claim.

Date of Birth            Social Security #   

Street               

City                       State            Zip Code      

Insurance Company   

            Name         Subscriber/Cardholder Name   

                        Relationship to Subscriber:    Self     Dependent     Spouse    Other

                   ID #     Group #   

            Address  

           City               State         Zip   

            Other Insurance Information   

If further contact is needed, which method would you prefer

E-Mail Address                Daytime telephone