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 *

Year

Month

Day

Insurance Information *

Date of Service *

Year

Month

Day

Person to contact with claim status:

Contact Name *

Contact Number *

Provider (not practice) Name *

Practice State *

Comments