Insurance Submission

Do you believe your insurance company should have been billed?

If you believe that your insurance company should have paid all or a portion of an account placed with our office, and you would like us to submit your insurance information to our client for review, please complete the entire form below.

  • Consumer/Debtor Information

  • Claim Information

  • Doctor/Hospital
  • Insurance Company Information

  • Policy Information

  • When did this insurance policy start covering this patient
  • Is this policy through your spouse or parent?
  • Other Information

  • Accepted file types: jpg, jpeg, png, pdf, docx.
    Please attach a copy of the front and back of your insurance card.
  • This field is for validation purposes and should be left unchanged.