Missing Claims Inquiry

ADMINISTRATOR: Patrick McCullough TELEPHONE: (410) 850-8500 TELEFAX: (410) 850-8655 EMAIL: planoffice@mmpplans.com

Complete this form to help us research missing claims not sent to the client/provider.

Client Name: Claims type: Provider Name:

Email:

Tax ID:

NPI:

Patient Name: Date of Birth: Claim Info:

Patient Name: Date of Birth: Claim Info:

Patient Name: Date of Birth: Claim Info:

MASTERS, MATES AND PILOTS PLANS