Client Policy Services

Please complete areas that you need in the following Request form. A representative will contact you concerning this request within 48 normal business hours.

Your First Name

Your Last Name

Email Address

Phone Number

Fax Number

Please check one or more:

Order New ID Card
Order New RX Card
Order New Booklet

Insured Carrier Information:

Name of Insured
Social Security #
Ins. Carrier Name
Policy Name

Check a Claim:

Patient Name
Date of Service
Provider
Amount of Charge $

General Policy Questions

Please verify the letters from the image (not case sensitive)