All requests for sharing of medical expenses must be accompanied by a United Refuah Medical Expense Sharing Request Form (below), as well as supporting documentation from your provider.
Ideally, before going into your appointment, you should call your provider to request that they provide you with a “Superbill” at the time of your visit. Most providers will know what this is.
If the provider cannot produce a Superbill then ask for a CMS-1500 form. This form has previously been known as a HCFA-1500. Both of these forms are standard forms used by medical providers for billing purposes.
If neither of these forms can be obtained from the provider, then the provider must complete Section G on the United Refuah Medical Expense Sharing Request Form.
If the provider refuses to fill out this form (and cannot provide a Superbill or a CMS-1500) then you must fill out Section G of the United Refuah Medical Expense Sharing Request Form yourself, obtaining the necessary information from the provider.
Regardless of which of the above has been completed, i.e. Superbill, CMS-1500, or United Refuah Medical Expense Sharing Request Form, the next step is to submit the documentation to United Refuah using one of the following three options
Mail all documents to this address:
United Refuah Health Share
P.O. Box 470218
Broadview Heights, OH 44147
(Please keep copies of all forms and documents for your own record.)
Fax to this number: 440-510-0444
Upload scanned copies on our secure document submission portal at www.urhs.us
To download and print the form, click on the Download PDF arrow at the bottom right side of the form, open the downloaded PDF file, and print.