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Max File size allowed: 5120 KB (kilo bytes)
File Types allowed: .gif, .jpg, .png, .pdf

Please submit the EOB along with the CMS 1500/UB-04 to assist in the timely processing of claims.

File Type: Insurance card

  Explanation of Benefits (EOB)

  Check Request Form

  CMS 1500/UB-04/Physician receipt

Select file:

Patient first name:

Patient last name:

Member ID:   I do not know my member ID