Sending A Form or Document

 

* indicates a mandatory field.
Use the drop down below to select who is to receive an attachment.
*
*
Enter your assigned provider number.
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Enter the providers name
Telephone Number:
*
() -ext.
*
Claim form ID can be found on the explanation of benefit statement.
Please enter the plan member ID
Enter the patients last name
Enter the patients first name

Attach form or document * (Overall maximum per submission is 4 MB): Attach a document by clicking the browse button and following the instructions.  Acceptable file types (extensions) are: bmp, doc, docx, gif, jpeg, jpg, pdf, png, tga, tif, tiff, txt, xls and xlsx.

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By submitting this form or document, I acknowledge I have written authorization to submit personal information to the Carrier/Adjudicator/Third Party Payor, and for the Carrier/Adjudicator/Third Party Payor to exchange information with other parties as required and only when the information is needed to administer and/or to confirm the accuracy of the information in the form or document.
I agree the information provided is complete and accurate, to the best of my knowledge.