Interactive Forms

Case/Chronic Condition Management
& Shock Loss Assessments

Before beginning the online submission process, it is suggested that you view or print a copy of the form, then gather all the information required to complete the whole form. Because of the sensitive nature of the information requested, the information is not saved in your computer or our web server and cannot be retrieved to be finished at another time. Therefore, the form must be completed in a single session. Additionally, the online application limits the amount of time your browser can remain idle. If for any reason you stay on a single page for more than 20 minutes, all information entered will be erased from memory, and will have to be reentered.

If, at any time, you wish to discontinue the submission process, be sure to close your browser to ensure that any data entered is no longer viewable on your computer. All information is erased on your computer, as well as on the Hines & Associates, Inc. server, whenever your browser is closed.

REQUESTER INFORMATION

Name(Required)

GROUP INFORMATION

Group Name
Self Insured

INSURED INFORMATION

Name(Required)

CLAIMANT INFORMATION

Name(Required)
MM slash DD slash YYYY
Address(Required)

Carriers

PROVIDER INFORMATION

Services Requested

Services Requested(Required)

Comments

Attachment

Drop files here or
Max. file size: 128 MB.

    Need Help?

    If you need assistance, please give us a call.

    800-592-8097

    Submission

    All medical records can be submitted online, faxed or mailed to our office.

    CM Department at Hines & Associates, Inc.

    Fountain Square
    2728 Asbury Road
    Suite 205
    Dubuque, IA 52001

    800.735.1435