Claims Research & Review Form

Member Information

Patient's Name *

Patient Year of Birth

Email Address *

Fax

Daytime Phone

Street Address

City

State

Zip

Date(s) of Service in Question

Provider Name

Have you authorized payment of medical benefits to the provider?

yes no

Claims Issue (Please Check One)

No Response Received on Claim Claim Denial Disputed Incorrect Payment Received Other (please give description)

Comment/Description

Have you previously inquired on the claim(s) listed above?

yes no