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Print PDF for Service Request
Service Request
   Client Information
Date of Request: (mm/dd/yyyy) ClaimName:
Name of Person Referring: Email:
Phone: Fax:
Principal Reinsurer: TPA Name
(If Different)
Phone: Fax:
Group or Plan Name: Group/PolicyNo.:
Effective Date: (mm/dd/yyyy) Contract Type:
Specific Deductible:
Patient Information
Patient Name: Diagnosis:  
Employee Name: SSN:
Facility/Physician: Tax ID Number:
Date of Service: From: (mm/dd/yyyy)
To:
(mm/dd/yyyy)		 Total Charges:
Is Provider in a Network?: Name of Network:
Expiration Date (mm/dd/yyyy) Discount:
If yes, has policyholder authorization and cooperation agreement been obtained?
If we obtain a discount, can benefits be treated as if in-network?
If yes, at what percentage are benefits payable?
Please provide the following information prior to submitting for negotiation:
Claim is payable at:          Deductible/ Out-of-pocket(owed)

Over UCR

When are checks cut for group?   Other:

Has any payment been made on this bill?if yes, amount paid:  
Comments including any applicable benefit limitations:
+Attachment:  
+Please attach claim for online submittal
Client Activities On This Case
UCR Reduction

Prior Attempt to Negotiate?Outcome:  
Date Attempt Made
Contact Name
Contact Phone #
Services Requested





For Bill Review and Audits, please check the following boxes:





 
Days
Other
Agreement: Client represents that it has verified the patient’s eligibility for benefits and availability of benefits under the Group’s plan (and Excess Loss/ Reinsurance coverage, if applicable) and agrees to pay the Provider(s) the discounted amount within the time frame agreed upon between HSI and the Provider(s). If a discount is lost due to non-payment of the bill or payment outside the terms agreed upon between HSI and the Provider(s), HSI’s fee remains due and payable. Client agrees to pay HSI for Bill Review/Screening if Client: 1) requests this service or 2) if Client prevents HSI from initiating or completing a requested negotiation. Client agrees that the above information is accurate and that HSI can rely on this information and shall not be responsible for any losses resulting from inaccurate information. Network discounts must be reported on this form and must be valid and accepted by the Provider(s) to be recognized for net savings calculation.HSI does not guarantee payment of benefits under any Benefit Plan or Reinsurance/Excess Loss coverage and does not review the medical necessity of the services or appropriateness of the charges submitted for negotiation or Network Repricing.  
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