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Patients & Visitors Hospital Billing Billing Pages
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Provide Insurance Authorization

Please use this feature to submit requested insurance authorization information necessary to process your hospital services bill. If you have scanning and/or faxing capabilities, please submit authorization information to (216) 286-6163. Thank you.

Please, complete all fields marked with an asterisk (*), as they are required.
* Patient First Name:
 M.I.:
 * Patient Last Name:
* Requestor First Name:
 M.I.:
 * Requestor Last Name:
* Relation to Patient:
* Services were rendered at:
* Account Number:
* From Date of Service:
Calendar
To Date of Service:
Calendar
* Address

* City:
 * State:
 * ZIP:
* Country:
* Authorization Number:

Phone Number:
 Alternate Phone Number:
Email:


Additional Comments: