Based on a recent claim we received for medical treatment, it appears you may have had an injury. In order to process your benefits claim, we will need more information. We appreciate your providing us with the information requested on this form.
If you have any questions, please don’t hesitate to contact Member Services at 800.547.0421, Monday through Friday from 7:30 a.m. - 3:30 p.m., Mountain Standard Time.
PLEASE NOTE: We are not affiliated with your employer. Therefore, we will not share any information with any third party without your prior, written consent.
If your condition is a result of an accident (such as a motor vehicle accident, slip and fall, etc), please click HERE.