Claim Services, Inc.

Document Retrieval Specialists

To obtain a status report for a particular account via E-mail, complete the boxes preceded by an asterisk.

*Patient LAST Name:

*Patient FIRST Name:

*Hospital Account Number:

*Hospital Name:

City:

State:

*Requestor's Name:

*Phone Number:

*Email Address:

Web Address/URL:

Comments/Questions:

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Claim Services, Inc.

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