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 Name (First name/Last name initial ONLY)*Date of Service* Details of Problem (i.e. Reason for Rejection)*Any Additional DetailsNameThis field is for validation purposes and should be left unchanged.
