CLAIM STATUS REQUEST FORM

Claim Status Request

If you are a provider wishing to submit a new claim, please visit our CLAIM SUBMISSION FORM. To request the status of an existing claim, please complete the information below. We will provide you with an answer within 48 hours.

Your Contact Details

Please provide the following information so that we may contact you with any questions.


Provider & Patient Information

Please complete as much of the following information as possible.


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