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:

Logging into Vbas
A benefit question
Full-time student verification
A claim issue
Other

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