CLAIM SUBMISSION FORM

Submit New Claims

If you are a provider requesting claims status, please visit our CLAIM STATUS REQUEST FORM. To submit a new claim online, please complete the information below. We will forward the claim to the Claims Department within 24 hours.

If you prefer to submit the claim via fax please send it to 305-820-4033.

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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