Insurance Support Your Name* First Last Phone Number*Email* Which TherapyAppointment system are you using?*Legacy System2.0 SystemAre you submitting claims via your own Office Ally account or through TherapyAppointment Claims?*My own Office Ally accountTherapyAppointment Pay-Per-Claim SystemClinician Name* First Last Patient Initials*Date of Service* Date Format: MM slash DD slash YYYY Details of Problem (i.e. Reason for Rejection)*Any Additional DetailsDO NOT INCLUDE THE PATIENT NAME OR ANY PHI (PROTECTED HEALTH INFORMATION) IN THIS SECTIONCommentsThis field is for validation purposes and should be left unchanged.
