Hospital Provider Form

If you're looking to submit a claim for a patient as a hospital provider, complete the form below and we'll get back to you as soon as we can.

Please submit only 1 claim per webform.

Hospital name
*Hospital name required*Hospital name requiredPlease enter the name of the hospital provider

Hospital provider number
**Please enter the hospital provider number

Provider contact phone number
*Contact phone number required*Contact phone number requiredPlease enter a contact phone number

Provider contact email address
*Provider contact email required*Provider contact email requiredPlease enter the contact email address

HIF member name
*Member name required*Member name requiredPlease enter the name of the HIF member

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