Submit Sharing Request - United Refuah HealthShare

Sharing Request Details

Name(Required)

First Last

Email(Required)

Phone(Required)

Member ID Number (Type 0000 if not yet a member)(Required)

Submitted by:(Required)

United Refuah Member

New Applicant

Doctor / Hospital / Other Medical Provider

Has this bill already been paid?(Required)

Yes (Please include proof of payment)

Partial Payment Made - Additional Payment Still Due

Visit Type:(Required)

Please specify visit type:(Required)

Diagnosis (visit reason):(Required)

Please specify diagnosis:(Required)

Procedures:(Required)

Please describe the services that were performed at this time of this visit (e.g. strep test, flu test, EKG, ingrown toenail removal etc).

Comment

File

Please submit original files or high quality scans in PDF or JPG format. If you are taking a picture with a phone, we recommend using a scan utility such as CamScanner.
For sharing requests, please ensure that you are submitting an itemized bill that lists the CPT (procedure) and DX (diagnosis) codes for each line item. If your provider has given you a standard insurance claim form, it already contains this information.

Drop files here or

Accepted file types: pdf, jpg, png, doc, docx, jpep, Max. file size: 2 GB.

Please note: Each sharing request must be submitted separately, using its own individual form. Each submission should include:

Proof of visit (e.g., itemized bill or medical record)
Proof of payment (e.g., receipt, EOB, or credit card statement)

Do not combine multiple requests into a single upload.

Sharing Request Details

Please note: Enrollment for June membership ends on May 10th.

Please note:
Enrollment for June membership ends on May 10th.