Service Resolution Form

BIS Benefits, Inc. (BIS) has partnered with your employer to leverage competitive insurance choices for you and to expedite the processing of any claims, service problems or benefit questions that may arise. When assistance with a service is needed:

  1. Call your insurance company/carrier directly. Most problems can be resolved through direct contact by the employee. The insurance company telephone number, policy number and ID numbers are found on your insurance ID card.
  2. If you still have questions about your claim:
    1. Complete this Service Resolution form in its entirety
    2. Fax the explanation of Benefits (EOB) and other supporting documents to BIS Benefits at 678-992-0242.

Note: This form is used to authorize BIS Benefits, Inc. to use or disclose your Protected Health Information (PHI) to the individual(s) or class(es) of persons (organizations) you designate and for your authorized representative to disclose PHI to the carrier for the purposes stated on the completed form.

By typing in your name below you acknowledge that you have had full opportunity to read and consider the contents of this authorization, and understand that, by filling in your name, you are confirming the authorization of the use and/or disclosure of your protected health information, as described in this form.

  • Claim Information

  • Home Address

  • Doctor / Facility Info

  • This field is for validation purposes and should be left unchanged.