Claims Report Request

Request Type:

Note: Only authorized personal may request reports. If you are unsure, please email to see if you qualify.

MM slash DD slash YYYY

*Note: Reports generally take 5-7 business days to process and be built. We will try our best to
accommodate the date provided.

What fields needed on the report?

Patient information/visit:

How often does the report need to be run?

EHR Team Only

MM slash DD slash YYYY

Please enter your name