Claim Services, Inc.

Document Retrieval Specialists

Use this form to refer an account to our staff.  We will send you a confirmation email.  If you would like to check the status of our progress, please click the 'Account Status' button to the left.

If you prefer to fax your referral, please click here:

Hospital Name:

Requestor's Name:

Phone Number / Extension:

Fax Number:

Patient Name:

Hospital Account Number:

Total Charges:

Date of Service:

To:

Claim Form

COBRA Application

COB

Birth Certificate

Add Baby to Policy

Accident Details

Death Certificate

Lien Information

Marriage Certificate

Medicare Liability Form

Medicare Questionnaire

Non-Availability Statement

PCP Referral

Subrogation Form

Police Report

Pre-existing Questionnaire

Authorization to Release Records

Student Status

Update Common Working File

Other (Please describe below)

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Claim Services, Inc.

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