Provider Information Requests

The below online request forms are provided to help us accurately answer your questions. Please complete one of the below online forms and click on the "Submit" button. NOTE: Form response times may take up to 21 days.

Request Explanation of Payment (EOP)

If you would like duplicate copies of an Explanation of Payment (EOP), please complete the EOP Request form below and click on the "Submit" button. NOTE: If you receive an electronic EOP, we are unable to provide specific details. You will need to contact your IT department for that information.

Patient/Member Name*

Patient/Member Date of Birth*

Patient/Member ID*

Date(s) of Service*

Billed Amount of Service*

Clinic or Provider*

NPI or TIN*

Email*

Fax*

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Provider General Information Requests

For General Provider Inquiries please complete the form below and click on the "Submit" button. Please note it may take up to 21 days for a response to this inquiry form.