ALL MEDICAL BILLS TO BE PAID OR REIMBURSED MUST BE SENT IN ALONG WITH THE “HCFA 1500/UB92 FORM”. MOST PROVIDERS HAVE A COPY OF THIS FORM. THIS FORM MUST BE SUBMITTED WITH ALL SUPPORTING DOCUMENTATIONS AND RECEIPTS FROM YOUR PROVIDER.
When you call your provider to schedule an appointment, inform them that you are a cash-paying person(s). Also, let their office know that you will need a completed HCFA1500/UB92 form aka as a Sharing Request.
You can also download and print a “sharing request form” from the download section below on this page . If your provider is too busy or refuses your request, then ask his staff to help you complete this form. It’s very important to return this completed form to Ansari HealthShare sm.
Please scan your completed copy then upload it onto our secure document portal. Uploading your documents section can be found under the MEMBERS titled page dropdown. Then email, Fax or mail this form to Ansari HealthShare . We recommend that you always keep a copy of your records for yourself.
