Add Additional Claim
Total Reimbursement $
Claim documents must include the patient name, the provider name and address, the service date, the diagnosis code, the procedure code,
and the billed charge for the service. Please do not submit documents that are missing any of this required information.
File upload performance is dependent on your connection speed and geographical location.
You may experience issues loading large files from some locations.
If you experience such problems try reducing file size or sending during off peak internet periods.
Scanning images in black and white text modes will help reduce file size.
Alternatively you may fax documents to 866-201-0522.
If you experience problems loading large files, try reducing the file size, scanning images in black & white, or sending during off
peak internet periods.
Accepted File Types: jpg, pdf, png, tif
(Size Limit 5 MB per file)
NOTE: Your files will not start uploading until you click submit.
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For a printable form click here