Verification of Benefits

Enrollees and providers can use the form below to request a Verification of Benefits. The Verification will contain an exhaustive summary of coverage and enrollment details and will answer most questions enrollees may have about their benefits, dependents and current coverages:

All requests for assistance are processed Monday through Thursday, 9AM - 5PM and Friday 9AM - 3PM Central Time. Whenever possible, IMA will respond to all requests within one business day.

Requester/Provider: Name & Phone Number

Requester Name:

Requester Phone:

() -

Participant: Employer & Group #

Employer Name		Group Number

Participant: Name, Date of Birth and/or SS#

First Name	MI	Last Name	Date of Birth (MM/DD/YYYY)		Social Security #
			//	AND/OR	--

Patient (if other than Participant)

First Name	MI	Last Name	Date of Birth (MM/DD/YYYY)		Social Security #
			//	AND/OR	--

Preferred Method of Reply (Email, Fax, Mail)

	Email (Will send VOB as PDF)
	Email:
	Fax No. (Will fax VOB)
	Fax #: () -
	Mailing Address (Will mail VOB)
	Address City State AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY Zip -

Submit Request