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Submit a Medicare Claim

If you are age 65 or older, have end-stage renal failure, or are permanently disabled, you may qualify for Medicare benefits. We can help you by submitting your Medicare claim for you.

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 *
Medicare Information
Medicare ID No.: * Part A Effective Date: *
  Part B Effective Date: *
If you are a member of a Medicare HMO, please provide the following information:
Medicare HMO Information
HMO Name: Phone:
Street Address: Identification No.:
City: Effective Date:
State: Termination Date:
Zip:  
If you have insurance coverage supplemental to Medicare that will pickup costs after Medicare's payment, please provide that information as
Supplemental Insurance Information
Carrier's Name: Phone:
Street Address: Insured's Name:
City: Identification No.:
State: Effective Date:
Zip Code: Termination Date:
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.

 

Still Employed?

If you are 65 or older, and you or your spouse are still working, your primary insurance provider may be your employers group health plan. Contact your employer if you have questions about your primary insurance provider coverage.

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