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Email Provider Relations

To facilitate your request and receive an E-mail response from HIP Customer Service, please provide the following information. This data will be automatically included in your E-mail message to HIP.

Provider/Hospital
Name:*
Provider/Hospital #:          
Patient ID #:*    -   
Patient Last Name:*
Patient First Name:*
Contact Name:
Contact E-mail Address:
Day Phone #:
DOS:*
$ Amount:*
Claim #:
Check #:
Message:*
Facilities:
Admitting Physicians: