HEALTH INSURANCE RESPONSE FORM – PRE-EXISTING CONDITION
 

Thank you for selecting the ISO Health Insurance Plan. HealthSmart is the claim administrator of your plan. (“Claims” are formal requests for the plan to pay for services you’ve utilized, usually submitted by the providers you see.) We have received a medical bill from your doctor and need additional information from you in order to complete our processing of your claim. Please provide the information listed below.

 
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5. During the period specified under the Remarks Code Section on your Explanation of Benefits (EOB) have you consulted any physicians? *
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HealthSmart
3320 West Market Street Suite 100 | Fairlawn Ohio 44333 | 800-203-4720 (tel) 806.473.3136 (fax)