First Name: 
  Last Name: 
    Address: 
    College: 

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. How was your claim submitted to the insurance company?

Mailed by Student Sent by Cutler Health By 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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