Claim service receipt notification

Service receipts summarize the number of claims submitted to Priority Health including upfront rejections.

Billing provider group information
Practice/facility billing/pay-to information as it will appear on each claim:

1. Group name *This question is required.

2. Tax ID *This question is required. 9 digit number This question requires a valid number format.

3. Group NPI *This question is required. 10 digit number This question requires a valid number format.

4. Street Address *This question is required.

5. City *This question is required.

6. State *This question is required.

7. Zip code *This question is required.

Office contact person

8. First name *This question is required.

9. Last name *This question is required.

10. Phone number *This question is required.

11. What email address would you like us to send receipts to? *This question is required. This question requires a valid email address.

12. Should receipts be forwarded to more than one email address?

13. What additional email addresses would you like receipts to be forwarded to? *This question is required.

Claim service receipt notification form