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Submit a Medicaid Claim

If you have health insurance through Medicaid and have received a hospital bill, we can help you by submitting a claim for you.

In the State of New York, all claims to Medicaid must be submitted within two years of the date of treatment.

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


Note: In the State of New York, all claims to Medicaid must be submitted within two years from the date of service. If you think you may be eligible for Public Health Insurance, you can call us at 1-866-381-1931.

Patient Information *Indicates a required field
Patient Name: * Hospital Account No.: *
Facility Name *
Medicaid Information
Medicaid ID No.: * Date of Birth: *
If you have Medicaid in a State other than New York, please provide the following information:
Medicaid Information
State: Medicaid ID No.: *

Carrier Information
Carrier Name: Zip:
Street Address: Phone:
City: Effective Date:
State:  
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 think you may be eligible for public health insurance, visit our Public Health Insurance page, or call us at (866) 381-1931.

Questions About Your Rights

The information above is provided as a service to you and is not intended as legal advice. If you have questions about your legal rights, please speak to your attorney or legal advisor.

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