Difi.az.govcontentform-soonbdrr-surprise-outForm SOONBDRR: Surprise Out-of-Network Billing Dispute ... 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your enrollee information, including first name, last name, email address, and phone number. Ensure all details are accurate.
3. Next, provide your insurance coverage information as it appears on your insurance card. This includes the name of the insurance company and member ID.
4. Fill in patient information if different from the enrollee. Indicate their relationship to the enrollee and date of birth.
5. Complete the healthcare provider details section with all known information about the provider who issued the surprise bill.
6. In the bill details section, enter specific amounts related to services provided, including total billed amount and required copayment.
7. Answer additional eligibility questions carefully to ensure you meet dispute resolution criteria.
8. Attach necessary documents as outlined in the checklist at the end of the form before submitting your request.

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