Appeals Form

If you wish to file an appeal of a ClaimReturn finding, please use this form to submit any pertinent information. We will respond to you as soon as your appeal has been evaluated by our team.

If for some reason you are not able to work with this form, please email your appeal with the same information as below to appeals@claimreturnllc.com.

NOTE: Fields marked by * are required, you will not be able to submit the form without all of the required information.

Name *

First

Last

Your Position

Healthcare Provider or Facility Name *

Provide Your Contact Information *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Fax *

Email *

Claim Number

ClaimReturn Case Number *

Your Patient Account Number *

Summary of your dispute *

Supporting Documentation

Click or drag a file to this area to upload.

Provider Password (as provided in EOB or letter) *