Provider Need Request Form
Please complete the form below. *Required Fields
Sender
*
Send Request To:
*
Please Select
Favored Medical Maternity Dept
Salt Lake Dermatology
Valley Dermatology
Other
Provider Email
*
Provider Name
Provider Email
CC: Email
Patient Full Name *for missing EOB use Unknown
*
First Name
Last Name
Patient DOB
*
-
Month
-
Day
Year
Please select an option that best fits your needs:
*
Claim Status – If you have NO information on the claim and need claim follow up
Question regarding processed claim – If you have a question regarding received correspondence / payment
Refund Request – If you have a request for refund
Missing EOBs – If you have received payment(s)and cannot match it to a patient
Account Ledger – Billing and payment account detail
Corrected Claim request – If a claim was processed and require changes
Other – Don’t see what you need help with? Tell us?
Claim Status
If you have NO information on the claim and need claim follow up
Date of Service
Date
Date
Date
Date
1.
Status Type
Family Account (select if you would like all the claims for a specific family status)
Provider Account (select if you would like ALL claims for your practice status) *Jan/ April/September
Name
Date of Birth
-
Month
-
Day
Year
Question Regarding Processed Claim
If you have a question regarding received correspondence / payment
Date of Service
Date
Date
Date
Date
1.
Concern
Refund Request
If you have a refund request
Date of Service
Date
Date
Date
Date
1.
Concern
Missing EOBs
If you have received payment(s)and cannot match it to a patient
Date Payment Received
-
Month
-
Day
Year
Amount Received
Received Format
Bank Deposit
Paper Check
Please Upload Copy
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of
Account Ledger
Billing and payment account detail
Date Span (Start)
-
Month
-
Day
Year
Date Span (End)
-
Month
-
Day
Year
Ledger Options
Entire Account (select for entire account)
Include Family (select to include a ledger for all family members)
Corrected Claim Request
If a claim was processed and require changes
Date of Service
-
Month
-
Day
Year
Change:
to:
.
ADD to the claim billing
Other
Don’t see what you need help with? Tell us?
Details
Please provide us any additional information that is helpful to your request
Please Upload Your Letter to Us:
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Cancel
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Submit
Should be Empty: