ASC Add/Change Request for Claims Billing Report Recipients

Please complete the information below to add a new recipient or replace an existing recipient of the ASC claims billing reports.

Employer Name:

Group Number:

Requestor Name:

Requestor Title:

Please remove the following from the distribution list:

I am a new recipient of the claims billing reports
I am a replacement contact for the claims billing report

New Contact Information:

First Name:

Last Name:

Email Address:

Phone Number:

You have the opportunity to select one of two invoicing formats that will be most useful for your needs and/or requirements. Please select the report option below that you would like to receive:

Option #1 - Management Cover and Summary Report
Option #2 - Management Cover, Summary Report and Detail Claims Report

* Denotes Required Fields

Please note that the Detail Claims Report is a member-level summary highlighting pay date, masked social security number of the subscriber, patient name, relationship type, claim ID, date of service and amount of claims dollars paid. The detail is subtotaled by relationship type as well as store location. The recipient will be required to log into CISCO Registered Envelope Service (CRES) before opening the message or attachments.

I understand that this Change Form will not be signed in the sense of a traditional paper document and instead will be signed electronically. I acknowledge and agree that by clicking the “Sign & Submit Change Form” button below, I will be affixing my electronic signature to this Change Form. I also understand that I may download and print a signed copy of this form by clicking the "Print/Save Completed Change" button on the next page.

I have read and agree to the above statement.