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MEDICAL PROVIDER INQUIRY FORM

This inquiry form is for bill payment status only. In order for us to assist you with your inquiry, please provide the following information. We will attempt to respond to your inquiry within 5 business days.

Please note that Arizona Workers’ Compensation law allows the carrier 30 days from date of receipt to process medical billings for payment (provided the claim is accepted and all required information is provided). Requests for payment status will not be responded to if the request is received less than 30 days from the date of service and/or the date the billing was mailed to the Alliance. Further, medical billings cannot be considered for payment without providing the associated medical records. You may submit medical billings and records via US Mail or fax. The main fax number is (602) 200-9600.



Provider Name:
Provider Contact Information:
      Fax:
      Phone:
      Contact Name:
      E-mail:*
1) Patient Name:* First:     Last: 
2) Date of Birth:*
3) Date of Injury:*
4) Date of Service:
5) Amount Billed:
6) Date Bill Mailed:
7) Patient Employer (School District): Please select School District
8) Alliance Claims Adjuster:
9) Provider please state your request: