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