Medical Provider Information
Please provide us with information about the physician, hospital, or medical facility that has billed you. We need this information in order to contact the medical provider to discuss your claim. Please review your medical claim (bill) and provide us with the information below:

Provider or Facility Name
  *
Address
Street *
Ste/Apt
City *
State *
Zip *
e.g. 12345
Phone
  *
e.g. (123)456-7890
Confirmation of Phone
  *
e.g. (123)456-7890
Fax No.
 
e.g. (123)456-7890
Provider Fed. Tax No.
 
if available
Patient Control No./
Patient Account No.
 
if available
* Required


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




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