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File a Claim
Step
1
of
6
16%
Terms and Conditions
(Required)
By proceeding I acknowledge and agree that I am voluntarily submitting information to assist Marvel Group in determining eligibility for a valid Patient Claim and that I have read, understand and accept the Surgical Stewardship Program
Terms and Conditions.
Patient Name
(Required)
First
Last
Date of original surgery?
(Required)
MM slash DD slash YYYY
Date of revision?
(Required)
MM slash DD slash YYYY
Hospital or ASC Name (Original Surgery)
(Required)
Hospital or ASC Name (Revision)
(Required)
Surgeon/Physician Name (Original Surgery)
(Required)
Dr.
Prefix
First
Last
Surgeon/Physician Name (Revision)
(Required)
Dr.
Prefix
First
Last
Health Insurance Provider
(Required)
Health Insurance Group ID
(Required)
Health Insurance Plan Number
(Required)
Name of Policy Holder
(Required)
Estimated total out of pocket expenses related to original surgery
(Required)
Phone
(Required)
Email
(Required)
