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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAmerican SamoaFederated States of MicronesiaGuamMarshall IslandsNorthern Mariana IslandsPalauPuerto RicoU.S. Minor Outlying IslandsVirgin IslandsArmed Forces Americas (AA)Armed Forces Europe (AE)Armed Forces Pacific (AP)AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuébecSaskatchewanYukon 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
