Healthcare Provider Verification for Current Hospital Stay

Applications are currently closed until October 17, 2022 to allow us to get caught up. We will be processing and paying on applications previously submitted. We look forward to reopening on October 17. Thanks so much!

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Your Name*
Hospital Address*
Reason for Application*

MM slash DD slash YYYY
Max. file size: 50 MB.
I agree that by marking yes, I am attesting that the information in this application is correct to the best of my knowledge.*
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