Your bill might qualify for mediation

We can start the process after you send the following documents and form to us:

1. Get these three documents together:
   • A copy of the front of your health insurance ID card.
   • A copy of your Explanation of Benefits (EOB) form. Your insurance company sends this form to you after you get health care services.
   • A copy of the doctor or provider’s bill.
2. Fill out the form and attach the documents listed in step 1:
   • English: Get help with a surprise bill you got from a health care provider
   • Español: Obtenga ayuda si recibió una factura sorpresa de un proveedor de servicios médicos