Provider Request Form
To expedite your request, please complete the information below.
Tell us what we can assist with:
*
Bill status
Claim Information (Claim #, Adjuster Info, etc.)
EOR and payment information
Appeal / Reconsideration
Other
Patient / Injured Worker First Name
*
Patient / Injured Worker Last Name
*
Patient / Injured Worker Date of Birth
*
-
Month
-
Day
Year
Date
Claim #
Provider Name
*
Date of Service
-
Month
-
Day
Year
Date
Billed Amount
Provider Reference #
Provider Contact Phone Number
*
-
Area Code
Phone Number
Provider Contact Fax Number
*
-
Area Code
Phone Number
Provider Contact Email Address
*
example@example.com
If you have several bill inquiries for the same injured worker, please list them below with any additional details that will help us respond to your inquiry:
Upload any documents that will help us respond to your inquiry
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