Claim Submission


Help with Claim Submission
Use this screen to submit your insurance information to our insurance billing department. This will allow us to verify your insurance benefits, and file insurance claims for you when you see the healthcare provider that directed you to this web page.

Insurance Information Submission Form


Use this form to submit your insurance information to us. If you have any questions, call Quick Claim at (210)683-7260.


Provider Name:
Insurance InformationVisit Information
Insurance Company:
Customer Svc Phone#:
First visit (mm/dd/yy):
Insurance Member Id#:
Insurance Group#
DescriptionPatient InformationSubscriber Information
(Only needed if policy is NOT in your name)
Last name
First name
Address 1
Address 2
City
State
Zip
Date of Birth (mm/dd/yyyy)
Employer or School
Phone
Email
Marital status
Gender MaleFemale
Work status Full-Time Student
Part-Time Student
Employed
None
Relation to subscriber Self
Spouse
Child
Other
Additional comments: