CLAIM STATUS REQUEST FORM

Provider Services:

Providers Name*:

Providers Tax ID:

Providers Email/Fax*:

Providers Phone*:

Patient's Name*:

Patient’s Member ID Number*:

Patient’s Date of Birth*:

Date of Service*:

Total Amount Billed*:

Date Submitted to URHS:

Form of Submission:
MailEmailFaxUpload

Comments: