Employee Name *
Prefix
First *
Last *
Suffix
Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Phone Number

###		-
###		-
####
Phone Type

Alternate Phone Number

###		-
###		-
####
Extention
Atl. Phone Type
Fax Number

###		-
###		-
####

Email Address *
By supplying an email address, you will receive a confirmation email from LifeWell Health Plans with a printable record of your request.

This information will not be sold or used by LifeWell for any other means.
Newsletters?
 YES 
 NO 
Would you like to receive our email newsletter with the latest LifeWell information and tips?

Enrollee/Employee ID *
This is found on your LifeWell ID Card.
Group Name or Number *
This is found on your LifeWell ID Card and is the company the subscriber works for.

Type of Inquiry *
 Claim  
 Benefits  
 PreCertification  
 Referral  
 Other  
Please select the type of inquiry above and provide as many details below for research as possible.

Patient Name *
Prefix
First *
Last *
Suffix
Claim Number
(if applicable)
Provider Name
(if applicable)
Date of Service
(if applicable)

MM		/
DD		/
YYYY
Check Number
(if applicable)
Dollar Amount of Claim
(if applicable)

Detailed Summary of
Issue or Inquiry *
Preferred Method of Contact
LifeWell will respond to the above chosen preference.

Upload a File
Please submit any copies of EOB's, checks, or medical/dental statements for review if applicable.

**NOTE: After you click Submit Inquiry you will be directed to our Thank You page. If you are not redirected please scroll up and make sure you have completed all required fields.
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