| Provider Name*: | |
| National Provider Identifier Number (NPI)*: | |
| Contact Name*: | |
| Contact Phone*: | |
| E-mail Address*: | |
| Is this regarding a specific member, claim, or benefit? | Yes
No |
| Member Name*: | |
| Presbyterian Member # or SSN*: | |
| Presbyterian Claim Number*: | |
| Presbyterian Date of Service*: | |
| Billed Amount*: | |
Reason for Inquiry*:
|
| Attach Supporting Documentation: |
File 1: |
File 2: |
File 3: |
