If you were unable to provide complete insurance information (insurance card or ID) at the time of your treatment, you can use this secure form to submit information online. This will help us process any insurance claims for you, and provide us with necessary information for a more accurate billing statement.

You can also contact an Intermountain representative, if you prefer, by calling 1-800-442-1128 during regular business hours.

* Designates required information

Personal Information
Service Information
Select a date from the calendar.
Insurance Coverage
Primary Insurance
Select a date from the calendar.
Secondary Insurance
Select a date from the calendar.
Comments

Copyright © , Intermountain Healthcare, All rights reserved.