Patient Eligibility Request
Fill out the form below and Bento will secure email or fax you the requested information about your patient's benefits. Note that any history requests require a predetermination form.
Patient's Full Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
Bento Member ID
*
Do you want to request a 2nd patient's information?
Yes
No
2nd Patient's Full Name
*
First Name
Last Name
2nd Patient's Date of Birth
*
-
Month
-
Day
Year
Date
2nd Bento Member ID
*
Do you want to request a 3rd patient's information?
Yes
No
3rd Patient's Full Name
*
First Name
Last Name
3rd Patient's Date of Birth
*
-
Month
-
Day
Year
Date
3rd Bento Member ID
*
Requested Information
Please note, Bento does not use a PayerID, nor do we use Group Names/Numbers. If a group name is needed, use the Employer name.
Below are the items we will send you. Deselect any you do not need.
Benefit Plan Summary (DCS)
Deductible/if it has been met
PDS/BRS/MRS coverage and breakdowns
Annual Max Total/Remaining Balance
Claim Submission Instructions (Portal, Fax, Mail)
For Patient History, please upload a predetermination form.
Browse Files
Cancel
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Enter in any other questions you would like us to answer or list any specific service codes you had questions on.
Your Office Information
Please fill out the below information that we will use to verify your office and then securely email or fax the information.
Name of Office/Practice
*
Office Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Phone Number
*
-
Area Code
Phone Number
Office/Practice TIN or Tax-ID
*
This will be used for verification purposes only. If you have not filed a claim with Bento before, Bento will call you to verify this request.
Do you prefer being emailed or faxed?
*
Secure Email
Fax
Office Email
example@example.com
Office Fax Number
-
Area Code
Phone Number
Submit
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