Cooper Benefit Consultants, Inc.

If you would like us to help you with a claims or service issue, just fill out the form below. Cooper Benefit Consultants is here to help you anyway we can. Please give us all of the details, and we will get back to you by the end of the business day. *REQUIRED

*Employee First Name:

*Employee Last Name:

*Employee Social Security Number:

*Patient First Name (If Not Employee):

*Patient Last Name (If Not Employee):

*Patient Social Security Number (If not Employee):

*Patient Daytime Phone Number:

*Patient Email Address:

*Employer Name:

*Doctor / Facility Name:

Doctor / Facility Address:

City:

State:

Zip:

*Date of Service:

Type of Service:

*Total Bill Amount:

Today's Date:

Questions and Comments: