Claim Information
Please provide the information below regarding your medical claim (bill).
Date of Service From
Date of Service To
*
Required
mm/dd/yyyy
Format Incorrect
*
Required
mm/dd/yyyy
Format Incorrect
Was the medical provider you visited an
“ In Network” provider?
Yes
No
Don't know
Not Applicable
*
Required
What was the total amount of the provider’s original charge?
*
Required
Format Incorrect
What amount (if any) has been paid by an insurer?
*
Required
Format Incorrect
What amount (if any) have you paid?
*
Required
Format Incorrect
What is the remaining amount due to the provider?
*
Required
Format Incorrect
Must be
greater
or
equal
to $1000.00
* Required
H.H.C. Group • 9420 Key West Avenue, Suite 330, Rockville, MD 20850
consumer@hhcgroup.com