Claims Assistance

Please fill out as much information as possible and press the submit button below for NHCAI to initiate work on this claim.

Employer:
Group #:
Employee Name:
Social Security #:
  (no hyphens)
Patient Name:
Date of Claim:
Purpose of Claim:
 Accident
Sickness
Injury at home
Injury at work
Medication
Provider Name:
Provider Address:
City, State, Zip Code:
Provider Phone:
  (no hyphens or brackets)
Enter any payment information made on this claim
(if none, enter '0')