Insurance Claims Issues

Student First Name *

Student Last Name *

Student ID *

Student Email *

Student Date of Birth * +

Area Representative Name *

Host Family Name *

Area Representative email address *

RD Name *

Who is submitting this form? *

Email of person submitting this form if not the student

Please complete all fields below prior to submitting this form.

Name of Medical Facility Visited *

Name of the provider *

Address of Medical Provider *

Date of Visit * +

Reason for Visit *

Please state the reason given for the denial of your claim. *

Please upload a copy of your ITEMIZED bill here. If you do not have an itemized bill, please do not submit this form. *

Upload Student Insurance Card (required) *

Additional Documents

Todays Date * +

Status notes (with dates) so we all know what has been done so far to remedy the problem. PLEASE ADD INITIALS NEXT TO NOTE WHEN ENTERING AN UPATE.