** All information is required for review. Information provided is private and confidential. **
NOTE: These benefits are applicable only if the patient is an eligible enrolled member of a HealthChoice plan. All benefits are subject to the deductible,
coinsurance and policy provisions. Please verify benefits and eligibility by calling the medical claims administrator toll-free at 800-323-4314.
MEDICARE PATIENTS: If HealthChoice provides coverage that is supplemental to Medicare, all requested services must be approved by Medicare. The Medicare EOB should be filed for claims processing.