ER Contact Form

Provider ER Contact Form

Provider may use this form to fill out an ER Contact Form.

Fields listed with an "*" are required.

Mandatory *

Provider Number

Provider Name *

Please type your Provider Name

Provider Email Please provide a valid email, if none exists, leave blank

Field not valid (required or bad value)

Member ID *

Health Plan ID Number must be nine characters and begin with an H

Date of ER Visit

Field not valid (required or bad value)

Time of ER Visit

Hospital Name *

You must provide the Hospital Name

Has the PCP been called? Yes No

Has The Health Plan been called? Yes No

Enter a description of the problem:

Field not valid (required or bad value)

Ohio Valley/Mountaineer Region
TF: 1.800.624.6961
Email: hpecs@healthplan.org
Hours: Mon- Fri., 8:30 am to 5:00 pm

HomeTown Region
TF: 1.800.426.9013
Email: hpecs@healthplan.org
Hours: Mon- Fri., 8:00 am to 5:00 pm

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