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*Corp Tax ID Owner: Select a Corporate Tax ID Owner MAIN HOSPITAL PHYSICIAN SALLY Phys/Provider Tax ID: Select a Tax ID 721356674 123456789 Phys/Provider Name: Select a Provider Dr. Sally Physician MAIN HOSPITAL, AZ -- 00001 Letter Date Range:  To: Letter Category: Claims Letter Type: All Additional information needed to process Authorization of therapy services Claim Reconsideration response Claim Status Update Claim acknowledgement Medical Claim Review Information Other Overpayment - reimbursement request Resubmit claim to correct network Subscriber Number: Patient's Last Name: Patient's First Name: *Claim Number: