Quick Claim Submit

Submit A Claim

Please review the below information carefully. If all information is correct, submit the form to send an electronic claim to Assist Health. Payment will be issued immediately and no further claims will need to be filed for the appointment.

Patient First Name(Required)

Patient Last Name(Required)

DOB(Required)

Services Scheduled(Required)

Appointment Date(Required)

Total Reimbursement Due(Required)

This will be the total amount on your check

Changes

Change appointment data

The Quick Claim feature cannot be used for appointments where the data does not align perfectly. In such cases, please submit your claim to Assist Health via mail, fax, email, or using our payer ID.

How would you like to be reimbursed?(Required)

If no payee information is displayed, it means our system does not yet have payee details for your center. This typically applies to new centers that have not yet processed a claim. To resolve this, you may either: Contact our Billing Support team at 888-996-0650 to add the necessary vendor information, or Submit your first claim as a regular claim. Once the initial claim is processed, payee details will be updated in our system for future transactions.

Submitter's Full Name(Required)

Submitter's Phone(Required)

Hidden

patient_record_id(Required)

Please agree(Required)

I confirm that the services rendered accurately match the CPT codes listed on this form.

Please agree(Required)

I confirm that the date of service matches the appointment date.

Phone

This field is for validation purposes and should be left unchanged.