Free Case Review

Paxos Free Case Review

Thank you for your interest in working with Paxos Health. Please complete this form, and we will reach out once we have had a chance to review your answers. Please write 'NA' in the fields that do not apply to your case for any non-health insurance-related claims, or fill them out to the best of your ability.
Email
Email verification
Please re-enter your email address.
Patient Name

First NameLast Name
Who is filling out this form?
If you are the patient, please write 'self'. If you are an authorized representative, please state your name and describe your relationship to patient.
Are you ready to move forward with our paid services, or would you prefer to begin with a free case review? Please note that the case review process may take up to 5 business days, which could delay our ability to start working on your case. If you're confident in proceeding, we recommend skipping the review to expedite the process.
Which of our services are you most interested in at the moment? This is not a commitment, but we encourage you to read through the service descriptions on our website (paxosappeals.com/appeals-service).
Who is your current medical insurer?
What state are you located in?
What state will your service performed in?
If the service already occurred, what state was it performed in?
What treatment (surgery, medical service, etc.) are you having?
What are the medical diagnoses related to your treatment?
Has your treatment been scheduled or happened yet?
Has your provider submitted a pre-authorization yet?
Date of procedure (or estimated date)
Please provide the exact date when your medical procedure took place, or if it hasn't occurred yet, give your best estimate of the upcoming date.
Date of most recent pre-authorization or claim denial?
Please answer in MM/DD/YYYY format.
Name of your surgeon/treating provider
How did you hear about Paxos?
Examples include internet search, word-of-mouth, physician referral, lawyer referral, online community names, etc.
Please elaborate on your answer above if you can.
First and last name, office, firm, website etc.
Please upload your denial letter, or any other pertinent letters your insurer has sent you relating to this case

Cancelof
If you're unable to upload a denial letter, please provide additional details explaining why.
Please upload your full insurance plan document (optional)

Please upload your plan document, also referred to as a benefit booklet or evidence of coverage (EOC) so our team can check plan language that may be relevant to your case. This is typically an 80+ page document found on your insurance portal. If you are unable to find this document at this time, you may skip this step for now and we will retrieve at a later date.
Cancelof
Please upload any appeals previously written and/or submitted (if applicable)

Cancelof
Tell us more about your situation. Please provide as much detail as you'd like for our team to review in our analysis of your case.
Should be Empty:

Paxos Free Case Review