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

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 you do not see any options here, it means that no payee information is available in our system. You will need to submit a regular claim first.

Submitter's Full Name(Required)

Submitter's Phone(Required)

Hidden

patient_record_id(Required)

Phone

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