(877) 628-2865


Please fill this report out to the best of your ability, if you have any questions call our claims department immediately. Once your claim is submitted you will receive a confirmation email that it has been received. Do not place this form or email in the patient’s medical chart.


Next Steps: Sync an Email Add-On

To get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page: (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020). Important: Delete this tip before you publish the form.


Please provide the required information for the individual reporting the matter ("Reporter")
MM slash DD slash YYYY
Reporter Name(Required)
Reporter Email(Required)


Insured Full Name(Required)
Insured Practice State
Insured Email(Required)


Full Name(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
Drop files here or
Accepted file types: jpg, png, pdf, Max. file size: 150 MB.
    Please attach any claim related correspondence, legal documents and medical records related to this patient prior to submitting form. You will receive email confirmation upon our receipt of your submission.
    Would you like a copy of this report?
    This field is for validation purposes and should be left unchanged.