Skip to main content

Medical Records Request

A scan sheet is required to be attached to all medical or dental records to facilitate quickly matching the records with the correct claim. If records are submitted without the scan sheet, they will be returned to you.

Please do not submit records unless the claims administrator requests them. A separate scan sheet must be completed for each claim for which you are submitting records.

It is important that the claim number, found on your remittance advice, be included on the form.

For questions, call the medical and dental claims administrator toll-free at 800-323-4314. TTY users call 711.

4151

Group Label:

Back to Top