General Customer Data Notification Questions

General Customer Data Notification Questions

Responses to this form may take up to 2 to 4 business days.

Company Name*

Company Street Address*

Company City*

Company State*

Select

Company Zip*

Company Relationship with Change Healthcare*

Payer

Provider

Partner

Company's Change Healthcare Account Number*

Can be found on contract or invoice.

Product(s)*

Please refer to the Solution Status page for product name

Contact Name*

Contact Email*

Communication Received*

Email

Letter

Both

Customer Question*

Send me a copy of my responses

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