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PROVIDER FORM
Please complete this form and then
click on the submit button at the bottom of the page.
(See below for faxing and mailing options)

Participating Practitioners Claim Form

PATIENT INFORMATION...
Employee 8 Digit Coordinate Number* (Required)
Employee Name
Patient Name
Date Of Service* (Required)
*About Coordinate Number - Addendum Benefit Administrators assign a four-digit number to each group. Each employee's coordinate number consists of that four-digit number plus the last four digits of their own social security number.
NOTE: ONLY CLAIMS THAT YOU KNOW TO BE QUALIFIED EXPENSES ARE COVERED
Requested Amount
BALANCE OF CLAIM NOT COVERED BY INSURANCE

PRACTITIONER INFORMATION...
Name / Title
Street Address
Suite# / PO Box Etc
City
State
 Zip Code
TAX ID NUMBER* (Required)
Comments
* Indicates a "Required Field". These Fields must be completed before form can be submitted
 
FAX FORMS...
You may print this page, fill in information and fax to
(585) 742-1492
 

Home <>Provider Form <> Contact Us
Addendum Benefits
PO Box 655
Victor, NY 14564

Phone 585-742-1052
Fax 585-742-1492
For more information E-mail Us

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