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Provider Check Tracers

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Use this form to submit a request for a check tracer.

Check Tracer Request Form

      

All fields are required
Representative's Name:
Representative's E-mail:
Title:
Is the check issue date less than 90 days? Yes No
Member Name:
Member ID:
Service Date:
Claim Number:
Payee Name:
Check Number:
Check Date:
Is the check date less than thirty (30) days ago? Yes No
Check Amount:
Line of Business:  PHP
 Salud
 PIC
 ASO
If check is not cashed, does customer want to stop payment and reissue? Yes No
Comments / Special Instructions: