Customer Support Request Form

Please take a moment to answer our brief questionnaire so we can service your information request.

*Name:

*Member Number:

*Employer Name:

*Phone:

*Email:

*I need help with:

Authorization - Verify authorization status
Benefits - Benefit question
Claims - Question about a claim
COB - Respond to letter inquiry
Cobra - Verify receipt of premium
Eligibility - Eligibility question
FSA - Question about Flexible Spending Account
FT Student - Full-time student verification
ID Card - Order new ID card
Retiree Premium - Verify receipt of premium
Vbas - Problem with Vbas Login/Access
Other (please explain)

If you are inquiring about a claim issue, please provide the following so we can better service your request:

Date of service:

Provider Name:

Billed Amount :

*Please describe your question:

*required field