Use this form to securely send your request for a pre-determination of benefits to our office. The data and documentation you supply here is protected during transmission to us, using industry standard encryption methods that satisfy stringent privacy laws and regulations, including HIPAA.
Please complete the form below. Fields marked with an asterisk (*) are required. You may send files up to 18 MB in size, in the following formats:
Image Formats: JPEG, JPG, GIF, PNG, BMP
Portable Document Format (PDF)
Spreadsheet Formats: .XLS, .XLSX, CSV
Word Processing Formats: .DOC, .DOCX
Use the “Browse” buttons to select your file for upload. Once you have attached the files you wish to upload, click the “Submit” button to complete your submission.