Please complete this form for the provider listed on the attached claim;
Common Ground Healthcare Cooperative (CGHC)
is unable to process the claim without this information. Please note that this document is for claims purposes only, and does not guarantee claims payment.
Please Note: Submissions are processed during business hours Monday through Friday from 8:00 a.m. to 5:00 p.m. Central Time (CT). Submissions received outside of business hours will be processed during the next business day.
