Client Service Form

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Client Service Form

For faster service, first please provide us with the following information:

Name: Phone:

Fax: E-mail:

Grp Name: Grp Number:

CLAIMS

Date of Service:		Provider's Name:
Patient's Name:		Patient's ID#:

My claim was denied

Fax a copy of your explanation of benefits or doctor's bill to us for review or
Call for explanation and advice.

My doctor has received no response from my insurance carrier on a claim that was submitted

Call Member Services to see if the claim was received. If not, ask your doctor to resubmit the claim.

Please get back to me on the following claims issue:

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BILLS

Billing Month:
Date of Invoice:

Credit was not given for last payment

Call billing to confirm that payment was received. If it has posted to your account, simply deduct that amount from your bill total and submit the current month's premium.

Make payment as billed and you will be credited or charged retroactive to the effective date on the next month's bill.

Call to confirm that employee enrollment or termination was processed.

Please get back to me on the following issue:

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ENROLLMENTS, TERMINATIONS & COVERAGE CHANGES

Employee Name:		Empl. ID#:
Eff. Term. Date:		Reason:

Enrollment / New Hire

Fax enrollment form for processing.
*Note: Please refer to the Employee Eligibility Page to confirm that enrollment is possible.

Please cancel the above employee from my group plan

Coverage change for an existing employee

Please call to confirm that changes can be made.
Fax Coverage Change Form / Enrollment form to us for processing.
*Note: There must be a qualifying event in order to make changes or add dependents onto a policy (i.e. birth, adoption, marriage, spouse lost other coverage, etc.). Please refer to your Employee Eligibility Page to confirm that changes can be made.

New employee has not received his cards

Call to confirm enrollment has been processed.
Call to confirm employee's address.

Please get back to me on the following issue:

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SUPPLIES

Send to (Name & Address):

Please mail directories - Qty:
Please mail enrollment kits - Qty:
Please fax an enrollment form
Please fax a medical claim form
Please fax a dental claim form
Please fax a prescription reimbursement form

Other:

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COBRA QUESTIONS

Please get back to me on the following questions:

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MISCELLANEOUS QUESTIONS OR COMMENTS

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