PatientPromise.com » File a Claim File a Claim Recently had spine surgery with a Patient Promise® Surgeon? If follow-up surgery is needed within 365 days, file a claim to receive up to $5,000. "*" indicates required fields Step 1 of 6 16% Terms and Conditions* By proceeding I acknowledge and agree that I am voluntarily submitting information to assist in determining eligibility for a valid patient claim. Patient Name* First Last Date of original surgery?* MM slash DD slash YYYY Date of revision?* MM slash DD slash YYYY Hospital or ASC Name (Original Surgery)* Hospital or ASC Name (Revision)* Surgeon/Physician Name (Original Surgery)* Prefix DRDr.MissMr.Mrs.Ms.Prof.Rev. First Last Surgeon/Physician Name (Revision)* Prefix DRDr.MissMr.Mrs.Ms.Prof.Rev. First Last Health Insurance Provider* Health Insurance Group ID* Health Insurance Plan Number* Name of Policy Holder* Estimated total out of pocket expenses related to original surgery* Phone*Email* CAPTCHA I agree to the HIPAA Privacy Statement
