Service Submission Form

Forsite Assist Request Form

Please follow the prompts to submit your service request to the Forsite Assist Service Team. We will be in touch shortly after your submission to assist!

Company Name *

Your Name: *

Your E-mail: *

Your Phone: *

Area Code Phone Number

What can we assist you with today?

I have to: *

Two pieces of information are needed in order to solve this issue:

1) The Explanation of Benefits from the insurance carrier

2) The bill from the doctor's office or hospital

With these two items, we will contact the insurance carrier directly and work with them to solve the issue. The account representative that services each account will ensure that the appropriate steps are taken so the claim is correctly processed in a timely manner.

Please provide any details that we may need in resolving this claim issue: (Do not include personal identifiable information such as SSN or DOB.) *

Please attach the Explanation of Benefits or any provider bills.

What is the effective date of termination? *

Month Day Year

What is the hire date? *

Month Day Year

Please attach a copy of the invoice(s) that you need help with. *

What specifically on the invoice(s) need to be fixed? *

Please attach the enrollment form: *

Upload a File

IF THIS IS URGENT, please contact our support office at 920-593-1275. Otherwise, we will follow up to ensure your employee gets the information necessary to gain access to care within 24-48 hours.

Please provide any necessary details so we can assist in getting the employee access to care: *

Please provide the employee's name: *

Please provide the insurance carrier's name: *

Please provide as much information about your human resources or compliance question as you can: *

Please provide as much information about your Affordable Care Act question as you can: *

What can we help you with? *

What is the reason for the termination? *