Medical Claim Inquiry
PIP/No-Fault
Enter your full name:
*
First Name
Last Name
Enter your email:
*
example@example.com
Enter your phone number:
*
Please enter a valid phone number.
Enter the name of the treatment facility:
*
Enter the Genoteq claim number:
*
Please enter a valid claim number. (If you do not have a valid claims number, please contact support (800) 960-1930)
Patient's name:
*
First Name
Last Name
Date of Service
*
-
Month
-
Day
Year
Date
Amount Billed:
*
What is your inquiry?
*
Please include any relevant attachments to your claim.
Browse Files
Drag and drop files here
Choose a file
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of
To proceed, please enter a valid claim number, and the submit button will appear.
Submit
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