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HIPAA Privacy Notice

How to Confirm Coverage (Medical and Dental Providers only)

The use of this form is intended for Medical and Dental providers only. If you are an individual seeking information about a filed claim, please click here.

By telephone:
1-800-256-8606

By fax:
1-877-365-9423 (toll free)
or
1-601-939-4495

By e-mail:
Please complete and submit the form below. You will receive an e-mail reply by noon (central time zone) the next business day advising the type of coverage and coverage status.

Policy / Coverage Information

Type of Service:
Medical Dental

Policy/Certificate Number:

Primary Insured/Employee/Subscriber:

First Name:

MI:

Last Name:

Claimant / Contact Information

Patient Name: (if different than primary insured)

First Name:

MI:

Last Name:

Name of Employer:

Physician/Clinic Information:
Full Name or Clinic Name:

Address:

City:

State:

Zip Code:

Phone Number:

Name and e-mail of person requesting this information
(must be the physician or an employee of the medical facility):

Name:

E-mail:

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