Provider Claim/Enrollment Inquiry

Please confine questions to one patient or member per form.

Note: This is a secure form so it can include personal health information related to your inquiry.

All fields are required except where noted

Your name*

Your email address*

Provider name*

NPI/Tax ID*

Patient ID number*

Patient's name*

Relationship to member (optional)

Member's name*

Member's home phone number (optional)

Member's work phone number (optional)

Member's work phone number extension (optional)

Subject (optional)

Admission/Service date*

Type of service (optional)

Procedure code (optional)

Charge (optional)

Paid date (optional)

Question*

Provider Claim/Enrollment Inquiry Success

Form Submission Success

Thank you for your Provider Claim/Enrollment Inquiry. A customer service specialist will contact you within one week regarding your inquiry.