Claims Service Form General Information Employee Name*: Employee Phone Number: Email*: Fax: Group Name: Employee SS#: Claim Information Date of Service: Provider Name: Patient's Name: Patient's DOB: : My claim was denied Fax a copy of your explanation of benefits of the doctor's bill to us for review or Call for explanation and advice. : My doctor has received no response from my insurance carrier on a claim that was submitted Call Member Services to see if the claim was received. If not, ask your doctor to resubmit the claim. : Please get back to me on the following claims issue:
