REPORT A CLAIM

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.

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REPORTER INFORMATION

Please provide the required information for the individual reporting the matter ("Reporter")

Date of Report(Required)

Reporter Name(Required)

First Last

Reporter Email(Required)

Enter Email Confirm Email

Reporter Phone(Required)

Reporter Company(Required)

Reason for Report(Required)

INSURED INFORMATION

Insured Full Name(Required)

First Last

Insured Policy Number(Required)

Insured Practice State

State

Insured Email(Required)

Enter Email Confirm Email

Insured Phone

PATIENT/CLAIMANT INFORMATION

Full Name(Required)

First Last

Patient Date of Birth(Required)

Treatment Date Triggering this Report(Required)

File Upload(s)(Required)

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?

Click here if you would like an emailed copy of this report

Phone

This field is for validation purposes and should be left unchanged.