Claims Assistance

Office Location:

Employer:

Employee Name:

Employer Email:

Phone #:

Patient Name:

Patient ID#:

Insurance Carrier:

Provider Name:

Provider Phone#:

Amount of Bill:

Date of Service:

Date of Service: :: Enter date in format YYYY/MM/DD

Description of Problem:

Upload PDF

Upload PDF :: Load only a pdf file under 5mb in size.

If completed filling out form, then type the bold characters in the box provided below. Case sensitive.

Verification

	Username:		Password:
	Retrieve your login information