PDF Forms
General Claim Form (long)
General Claim Form (short)
Accident/Incident Form
Authorization for Medical Access
Authorization for Prescription Access (MedTrak)
Personal Representative Authorization for Minor Child(ren)
Other Health Information for Insured or Spouse
Complete Health Insurance Verification-Insured
Complete Health Insurance Verification-Spouse
Complete Health Insurance Verification-Child
Condensed Health Insurance Verification Form (EE,SP,CH)
We're here to answer your questions.
1-800-777-9087
Claim Status Inquiry - Provider
*Provider Name:
*Person Seeking Status:
*How do you want to be contacted:
Email
Telephone
Fax
*Email Address:
*Phone Number:
Fax Number:
*Patient's Name:
*Patient's DOB:
*Relation to Employee:
Employee
Spouse
Child
*Employee's SSN:
*Employee's Name:
Employee's Phone:
Employer Name:
*Date of Service:
*Amount Billed:
Date of Service:
Amount Billed:
Date of Service:
Amount Billed:
Date of Service:
Amount Billed:
Date of Service:
Amount Billed:
Specific Question from Provider
Verification
As a means of added security,
we've added visual verification to our contact form. Please enter the code you see in the box to the left.
