Submit a claims inquiry

Securely send a claims request.

Claims Inquiry

Fill out this form and click “Send.” We will review your request and send you the claim information you requested.

Required

Claim Category

Contact Name

Practice Name

Mailing Address 1

Mailing Address 2

City

State

Zip

Contact Email Address

Contact Phone Number

Can we leave a message with the Contact?

Yes

Contact Fax

Member First Name

Member Last Name

Date of Birth

Member / Subscriber Number

Date of Service

Security Health Plan Claim Number

Billed Amount

Security Health Plan Payment

Denial / Rejection Reason

Questions / Comments