BMT Insurance Help Form

Insurance Help Form

If you are covered by an US insurance plan and your health insurance plan has refused to pay for all or part of your treatment, we can refer you to not-for-profit organizations and attorneys who may be able to help you. All the attorneys on our referral list have successfully persuaded insurers to pay for transplant-related expenses ... usually without resorting to litigation. They can help you appeal your insurance company's denial of coverage in a timely manner, so you can get proper treatment when you need it. If you'd like a referral, please fill out the following form or phone us with the information at 847.433.3313. The referral service is free of charge. The initial consultation with most attorneys is also free. Fees thereafter vary and should be discussed directly with the attorney.

Please provide us with information on how we can contact you: * Indicates a required entry
Name:	*
Address:	*
City:	*
State/Province:	*
Zip/Postal Code:	*
Country:
	One of the following phone numbers is required
Evening Phone:	*
Day Phone	*
Fax:
E-Mail:

Patient's Name (if different):
If you're not the patient, what is your relationship to the patient?	(other)
State patient lives in:
Name of insurance company:
Diagnosis (e.g., breast cancer, Hodgkin's, etc.):
Name of medical center where patient will have the transplant:
Have you already received a verbal or written denial?	Yes No
If you've received a written denial, have you or the transplant center formally appealed the denial?	Yes No
If only a portion of the procedure has been denied, which portion? (e.g., won't pay for testing unrelated donors)
Is the insured a federal employee?	Yes No
Is there any other information we should know?

We will respond as quickly as possible with the names of attorneys you can contact for help. If you haven't heard from us in 5 working days, please contact us again. We may be having trouble reaching you. If you need help immediately, please phone us at 847.433.3313, or toll-free: 1.888.597.7674.