If you are filing this form for multiple claims with one provider, you may print the form with the information completed up to the Patient's Name and then attach as a supplement the information from the Patient's Name through the end of the form. You would then file the form and the supplemental information in paper format. Contact Information First Name: Required Last Name: Required Email Address: Phone Number: Health Care Provider Information Health Care Provider Name: Address: Required City: Required State: Required Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas (AA) Armed Forces Europe (AE) Armed Forces Pacific (AP) Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Québec Saskatchewan Yukon Zip Code: Required Insurance Company Information Insurance Company Name: Plan Type: Patient's Name: Insured or Policyholder: Policy Number: Claim Number: Date Claim was Submitted: Submission Type Paper Electronic Description of Unfair Payment Pattern: Total file size for all files cannot exceed 17MB. File Upload 1 (pdf, xls, xlsx, doc, docx, jpg, png, gif, tiff, txt) File Upload 2 (pdf, xls, xlsx, doc, docx, jpg, png, gif, tiff, txt) File Upload 3 (pdf, xls, xlsx, doc, docx, jpg, png, gif, tiff, txt) Security Authentication Required
