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

###		-
###		-
####
Extention
Alt. Phone Type

Email *
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.
Newsletter?
 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.

Patient's Name *
Please list the name of the patient that the claim is for.
Prefix
Please list the name of the patient that the claim is for.
First *
Please list the name of the patient that the claim is for.
Last *
Please list the name of the patient that the claim is for.
Suffix
Please list the name of the patient that the claim is for.
Claim Number
The claim number is listed on your EOB and starts with either the letter D or E.

LOOK BACK PERIOD

Please enter the date span listed on the correspondence letter you received in the mail.
Treatment Dates beginning

MM		/
DD		/
YYYY
Treatment Dates ending

MM		/
DD		/
YYYY

Providers seen during time frame listed above:
 NONE 
List providers seen during above specified time frame.
Include provider's name, address, and phone number.

Medications taken during time frame listed above:
 NONE 
List medications taken during above specified time frame.
Include medication and dosage.

OTHER INSURANCE

Is this patient covered by any other Medical/Dental Insurance? *
 NO 
 YES 
If you selected YES, please complete the following 4 questions.
1) What is the name of the other insurance carrier?
2) Effective Date of the policy?

MM		/
DD		/
YYYY
3) Name of the subscriber of the other coverage?
Prefix
First
Last
Suffix
4) Date of birth of the subscriber?

MM		/
DD		/
YYYY

Upload a File
If you have any supporting documentation that you feel we may need to process the claim, feel free to attach it to this form.

**NOTE: After you click Submit Information 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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