Special Assessment Coverage Inquiry Form
Submit your request to determine if your service or coverage qualifies for special assessment coverage. Please complete all sections carefully.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Type of Service or Coverage Requested
*
Please Select
Medical Service
Rehabilitation
Equipment
Home Care
Other
Brief Description of Requested Service or Coverage
*
Has this request been previously submitted for coverage?
*
Yes
No
Urgency of Request
*
Routine
Expedited
Critical
How essential is this service or coverage to your current situation?
*
Not Essential
1
2
3
4
Absolutely Essential
5
1 is Not Essential, 5 is Absolutely Essential
Please rate your understanding of why this request may qualify for special assessment coverage.
*
1
2
3
4
5
Additional Comments or Information
Submit Inquiry
Should be Empty: