FEP Claim Inquiry

*Asterisks indicate required fields.

Please complete all fields of this form to ensure your FEP claim inquiry request is processed quickly and accurately.

*Office/Practice name:
    
*Tax ID:
    
*NPI:
   
*Requester Name:
*Requester Email address:
*Member name
*Member date of birth:
*Member number (including the R):
Claim number
    
Date of service:
    

Please provide the reason for your claim inquiry request: