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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:

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