Get Az Surprise Out-of-network Billing Dispute Resolution (soonbdr) Request 2022-2025

Completing the Arizona Surprise Out-of-Network Billing Dispute Resolution (SOONBDR) Request form online is a crucial step for users seeking resolution for surprise medical billing issues. This guide provides clear, step-by-step instructions to help users successfully navigate and fill out the form, ensuring all necessary information is included.

Follow the steps to complete the request form with ease.

1. Click the ‘Get Form’ button to access the form and open it in the online editor.
2. Provide enrollee information by entering details such as first name, last name, contact information, and mailing address. Ensure accuracy to avoid processing delays.
3. Fill in the insurance coverage information exactly as it appears on the health insurance card, including the name of the insurance company and member identification number.
4. Complete the patient information section. Indicate whether the patient is the same as the enrollee and, if not, fill in the necessary details for the patient.
5. Input the healthcare provider details. Include the provider's name, business name, and billing address along with contact information.
6. Detail the bill and service information. Enter the date services were provided, total billed amount, required copayment, coinsurance, and deductible information.
7. Answer the additional eligibility questions accurately. Review each question carefully to determine if the situation applies to you.
8. Provide information about any authorized representative if applicable. This person will receive notifications about the status of the dispute resolution request.
9. Review the dispute resolution request checklist and ensure that all required photocopies of supporting documents are prepared and attached.
10. Complete the attestation section by signing and dating the form, certifying that all information provided is accurate.
11. Once all sections are completed, save your changes, then download, print, or share the completed form as needed.

Begin filling out your SOONBDR Request online today to ensure your dispute is processed promptly.