Medical Insurance Coverage Issues

MEDICAL INSURANCE COVERAGE ISSUE FORM

At times, clerical error or a misinterpretation of a statement results in an insurance company’s refusal to pay a charge they receive. If your collections account with L J Ross is due to unpaid medical bills, that you believe to be the responsibility of your insurance company, please complete the form below or contact us today to help resolve your account. Please note that providing your insurance information is not a guaranteed resolution of your account. We recommend that you follow up with our office by telephone at 1-844-348-1739 to ensure complete resolution.

Personal Information

By checking this box, you are confirming that you are the named individual on this account and are authorized to review and discuss any personal information contained in the account. You further authorize LJ Ross Associates, representatives to contact you at by telephone at any and all numbers you have provided to discuss the account, including but not limited to contact via prerecorded messages and calls made by an automated telephone dialing system. You agree and confirm that the telephone number you provide belongs to you.

Insurance Information

Yes       No

Secondary Insurance Information

Yes       No

Legal Information

Work-Related       Personal
Yes       No
Yes       No
Yes       No

Email Disclaimer

You agree that LJ Ross Associates may from time to time make calls and/or send text messages to you at any telephone number associated with your account, including wireless telephone numbers that could result in charges to you. You hereby confirm that any number you provide belongs to you. The manner in which these calls or text messages are made to you may include, but is not limited to, the use of prerecorded/artificial voice messages and/or automatic telephone dialing system. You further agree that LJ Ross Associates may send emails to you at any email address you provide us or use other electronic means of communication to the extent permitted by law. You agree and acknowledge that any email address or any other electronic address that you provide is your private address and is not accessible to unauthorized third parties. You agree and acknowledge that you have requested that we send the document(s) you have requested to you at the email address you have provided. Consent may be revoked at any time and by any reasonable means.