Insured Name: 
Insured's Address: 
Insured's Address: 
City:       State:   Zip:  
Claim Number:   Account No:   
Policy Number:   Draft No:  
Dates of Service:  
Date Paid: Amount Paid: Amount Overpaid:
Payee Name:   Phone Number: 
Payee Address:  
Payee Address:  
City:       State:   Zip:  
Patient Name:  Relationship: 
Social Security Number:  
Brief Explanation of Overpayment:




Claim Submitted By:  
Company:  
Address:  
City:       State:   Zip:  
Fax Number:   E-mail Address: 

To Send in This Claim
Click Submit button to send it e-mail or
   click on File, then Print to printer and fax it to us at 
770-216-9353.  You can also print to your modem fax.  Remember to close your internet
connection if asked to do so. Then retry the fax.  

In placing accounts you  authorize us to act as your agent for
collection, contact your debtors, accept and endorse payments for
deposit, and remit net proceeds to you.
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