Instructions For Quick Claim Processing:

• Fully complete & sign this claim form

• Attach copies of supporting EOB, receipts, vouchers, bills, etc.

• All receipts must include a date, description, and amount of the service

• Please list one expense per line

• Please print in dark blue or black ink when using this form

• Please allow 2 business days for claims to be processed

Click the button above to open and download the form