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Benefits & Coverage
For Patients
For Surgeons
For Hospitals
Find a Doctor
File a Claim
About
FAQ
Contact
Benefits & Coverage
For Patients
For Surgeons
For Hospitals
Find a Doctor
File a Claim
About
FAQ
Menu
Benefits & Coverage
For Patients
For Surgeons
For Hospitals
Find a Doctor
File a Claim
About
FAQ
Contact
Patient Promise®
Our Claim Process
File a Claim
Terms and Conditions
terms& conditions
By proceeding I acknowledge and agree that I am voluntarily submitting information to assist Marvel Group in determining eligibility for a valid Patient Claim and that I have read, understand and accept the Surgical Stewardship Program Terms and Conditions.
Full Name
Your Age
Email Address
City
State
Describe Your Back Problems
Describe Your Back Problems
Describe Your Back Problems
Submit Your Application
Step
1
of
6
16%
Terms and Conditions
(Required)
By proceeding I acknowledge and agree that I am voluntarily submitting information to assist in determining eligibility for a valid patient claim.
Patient Name
(Required)
First
Last
Date of original surgery?
(Required)
MM slash DD slash YYYY
Date of revision?
(Required)
MM slash DD slash YYYY
Hospital or ASC Name (Original Surgery)
(Required)
Hospital or ASC Name (Revision)
(Required)
Surgeon/Physician Name (Original Surgery)
(Required)
Dr.
Prefix
First
Last
Surgeon/Physician Name (Revision)
(Required)
Dr.
Prefix
First
Last
Health Insurance Provider
(Required)
Health Insurance Group ID
(Required)
Health Insurance Plan Number
(Required)
Name of Policy Holder
(Required)
Estimated total out of pocket expenses related to original surgery
(Required)
Phone
(Required)
Email
(Required)
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.
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Patient Promise®
