PROVIDER PORTAL / CHECK CLAIM STATUS

Check Claim Status / Claim Inquiry

Please complete the form below for claim inquiries. Please allow 3 business days for a response. For more than four (4) inquires, please complete "Full Aging Request Report" provided below. Thank you.

1st Check Claim Status / Claim Inquiry
Date:Patient Name:
Patient DOB:Insurance Name:
Date of Service:Billed Amount:
Inquiry:
2nd Check Claim Status / Claim Inquiry
Date:Patient Name:
Patient DOB:Insurance Name:
Date of Service:Billed Amount:
Inquiry:
3rd Check Claim Status / Claim Inquiry
Date:Patient Name:
Patient DOB:Insurance Name:
Date of Service:Billed Amount:
Inquiry:
4th Check Claim Status / Claim Inquiry
Date:Patient Name:
Patient DOB:Insurance Name:
Date of Service:Billed Amount:
Inquiry:
Request FULL Aging report
Request FULL Aging report
Full Aging Report request should be made 45 days apart to give proper time for claims processing and previous request. Please allow 7 business for completion.
Provider/Facility Name:Provider Email^:
^This is a request for a complete aging report of my practice to be emailed to the provided email address.
*A copy of this completed form will be sent to your provided Sender Email address.


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