Complex Insurance & Medical Billing Advocacy Intake Form

Complex Insurance & Medical Billing Advocacy Intake Form

Help us understand your insurance and billing concerns to assist you effectively.
Client Information
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Contact Method
Emergency Contact Name

First NameMiddle NameLast Name
Insurance Information
Insurance Policies
Add up to 3 insurance policies. Enter one entry for each active or relevant coverage plan.
Provider & Facility Information
Providers / Hospitals / Facilities Involved
Dates of Service

MonthDayYear
Date
Type of Treatment or Services Received
Approximate Number of Providers Involved
Billing & Claim Issues
Issue Types

Other
Please describe what happened
What concerns you the most right now?
Have you spoken with the insurance companies or providers already?
Have any appeals already been submitted?
Have any accounts gone to collections?
Approximate balance owed
Claim number
Policy or member ID
Provider or facility name
Date of service
Deadlines & Urgency
Are there any upcoming deadlines?
Have you received collection notices?
Are you currently making payments on any balances?
Is your credit currently being affected?
Document Uploads
Please upload only the most relevant documents related to your current concern.
Insurance cards

Cancelof
EOBs (Explanation of Benefits)

Cancelof
Billing statements

Cancelof
Denial letters

Cancelof
Collection notices

Cancelof
Authorization letters

Cancelof
Timeline or notes, if available

Cancelof
Client Authorization
Acknowledgments
Electronic Signature
Date

MonthDayYear
Date
Consent to Contact
Authorization to Share Information
Preferred Authorization Scope
Should be Empty:

Complex Insurance & Medical Billing Advocacy Intake Form

Client Information

Insurance Information

Provider & Facility Information

Billing & Claim Issues

Deadlines & Urgency

Document Uploads

Client Authorization