Submit Insurance Information

Claim Details and Information

Please fill in the form below if you believe that payment was made. We will confirm so please be sure to include any and all relevant information.

Please enter your account number found on your statement.
Please enter your account number found on your statement.
Please enter your account number found on your statement.
Field is required!
FIRST NAME ON STATEMENT
Your First Name
Field is required!
LAST NAME ON STATEMENT
Your Last Name
Field is required!
PHONE
Your Phone Number
Field is required!
INSURANCE PROVIDER NAME
INSURANCE PROVIDER NAME
Field is required!
INSURANCE BILLING ADDRESS
(Back of insurance card)
INSURANCE BILLING ADDRESS
Field is required!
POLICY HOLDER
POLICY HOLDER
Field is required!
GROUP #
GROUP #
Field is required!
ID #
ID #
Field is required!
SUBSCRIBER DATE OF BIRTH
Select a date
Field is required!
PATIENT FIRST NAME
First Name
Field is required!
PATIENT LAST NAME
Last Name
Field is required!
PATIENT DATE OF BIRTH
Select a date
Field is required!
ANY ADDITIONAL INFORMATION
ANY ADDITIONAL INFORMATION
Field is required!
*If you have any questions about this form please contact Central Professional Services so that we may assist you.1-800-748-0031

This is an attempt to collect a debt. Any information obtained will be used for that purpose. You are now communicating with a debt collector.