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Submit a Health Insurance or Managed Care Claim

If you have health insurance through your employer, or if you have an individual policy, we can help you by submitting your insurance claim on your behalf.

Each insurance carrier has their own filing time limits, so please provide this information as soon as possible.

Please provide the following information so that we can submit your insurance claim:

 

Patient Information *Indicates a required field
Patient Name: * Hospital Account No.: *
Facility Name *
Insurance Information
Primary Insurance Coverage:
Carrier Name: * Policy Holder's Name: *
Street: * Identification No.: *
City: * Employer Name: *
State: * Effective Date: *
Zip Code: * Termination Date: *
Phone: *  
Seconday Coverage:
Carrier Name: * Policy Holder's Name: *
Street: * Identification No.: *
City: * Employer Name: *
State: * Effective Date: *
Zip Code: * Termination Date: *
Phone: *  
Contact Information
Email Address *
  I certify that I am the owner of the email account and I am the patient, the financially responsible party for the patient's account, or I am authorized to act on behalf of the patient.

 

If you have questions about your insurance carrier information, please contact the human resources department at your workplace.

If you have already submitted a claim and it has not yet been paid, please your insurance provider.

 

Additional Requirements From Your Insurance Provider

Your insurance provider may require you to provide a claim form or additional information before your claim is paid.

Managed care insurance companies (HMOs) may require authorization for services, including emergency services.

If you have questions about insurance coverage or filing requirements, please contact your carrier.

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