First Name: 
  Last Name: 
    Address: 
    College: 

 Email Address (required): 

1. What date were you treated?

2. What was the date when you submitted your claim?

3. What is the name of the provider? (ex. Doctor, Hospital or Facility)

4. What is the amount of your bill?

5. Do you have other insurance coverage, if so has your other plan paid 
any portion of this bill?

6. Did you send the claim form directly to the insurance
company, through the Health Center, or was it submitted 
by your physician's office? Health Center Physician

7. Was the claim paid to your satisfaction? Yes No

8. Do you have any suggestions or recommendations to improve
the claims paying process?

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