Provider’s Claim Status Request Form

To submit a claim status request, please complete the below form in its entirety and a representative will reach out to you and provide an update or send you an Explanation of Sharing.

Provider's Claim Status Request

Provider's Name:

Provider's Tax ID:

Provider's Email/Fax:

Provider's Phone/Fax:

Patient's Name

Patient's Member ID Number:

Patient's Date of Birth:

Date of service:

Total Amount Billed*:

Date Submitted to URHS:

Form of Submission:

Mail Email Fax Upload

Comments

Provider's Claim Status Request

Enrollment for March 1st has closed. Enrollment for April membership ends on March 15th.

Enrollment for March 1st has closed.
Enrollment for April membership ends on March 15th.