ADDITIONAL INFORMATION REQUEST CLIENT ... - Sentara.com 2026

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The document is an Additional Information Request form used to update billing information for medical services. It requires details such as patient information, insurance carrier data, and the ordering physician's signature to request credits for charges that may need to be billed to different payers like Medicare or Medicaid. The request must be submitted within 30 days of receiving the bill.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your Client Number and Statement Date at the top of the form. This information is essential for tracking your request.
Fill in the patient’s details, including their Social Security Number, Name, Date of Service, and Address. Ensure accuracy as this information is crucial for processing.
Complete the insurance information section. Include details such as Medicare ID, Medicaid ID, and Insurance Carrier information. If applicable, provide the effective dates of insurance coverage.
If there is a subscriber different from the patient, fill in their details along with their relationship to the patient.
Finally, ensure that a physician or designee's signature is included at the bottom of the form along with their contact number for verification purposes.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the email format for Sentara Healthcare?

In Sentara MyChart youll see a Request My Medical Records option in the menu. How do I check COVID-19 vaccine status and test results? Please refer to the COVID-19 section within your Sentara MyChart account. This is accessible from the menu under My Record.

What is the Sentara employee portal website?

Phone or visit: You can also call or visit your provider and ask them how to get your health record. Ask for the health information services department or the administrative staff in charge of releasing health records.