Thank you for taking the time to provide the information requested below. We are gathering this information to assist us in working with Rockefeller University Hospital and its insurance companies to try to resolve your claim, but please do not guess or feel compelled to provide answers to questions if you do not know the answer. For example, some of the questions ask about dates because certain insurance policies apply to certain date ranges. If for some reason you can recall those dates, the questions allow you to share that information with us. However, please do not be alarmed if you cannot recall the dates as we will likely have other ways to obtain the dates, such as your medical records.
We are providing this online form because some people find it easier to provide the information in this fashion. Please let us know if you would rather provide this information over the phone.
Please know that the information you provide to us will be kept confidential and will not be shared with anyone else other than Rockefeller University Hospital and its insurance companies. They have agreed to keep the information confidential as we try to explore an informal resolution of your claim.
Finally, we understand that you will likely recall more information as time goes on, so please only provide the best information that you can today. You are always welcome to share more information with us, and we will be clear to Rockefeller University Hospital and its insurance companies that we will likely provide more information down the road.
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