In order to expedite processing, all requests should be accompanied by a United Refuah Medical Expense Sharing Request Form.
Ideally, before going into your appointment, you should call your provider to request that they provide you with an itemized bill at the time of your visit. The provider may give you a CMS-1500 Form or a Superbill, both of which 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.
If you have already paid your provider for the medical services you have received, you MUST submit proof of payment together with your sharing request.
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 HealthShare
P.O Box 18523
Cleveland Heights, OH 44118
(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.URHS HS Needs Processing Form