Check on Claim Status

To check on the status of a claim please complete the required information below and your request will be forwarded to a member of the ActivHealthCare staff.

Insured Name: *

Patient Name: *

Member ID# (Policy Holder): *

Date of Birth: *

Insurance Information: *

Date of Service: *

Person to contact with claim status:

Contact Name: *

Contact Number: *

Provider (not practice) Name: *

Comments:

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