Patient Information
This is information specific to the individual who received treatment from a medical provider for this claim. This may or may not be the same individual as the responsible party / insured. To change any information, do so before selecting Save and Continue.

Name

 
First *
MI
Last *
Sex
  *
Date of Birth

  *
mm/dd/yyyy
Address
Same as Register
Street *
Ste/Apt
City *
State *
Zip *
e.g.12345
Patient’s Social Security Number
  *
e.g.123-45-6789
* Required


H.H.C. Group • 9420 Key West Avenue, Suite 330, Rockville, MD 20850
 consumer@hhcgroup.com
URAC




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