Gorah Enrollee Refund Form

First Name *

Last Name *

Email *

Middle Name *

Name of Company

Your Date of Birth

Home Address

GORAH Health Enrollee ID:

State

City

Name of Provider

Date of Encounter

Reason for Refund (Select one)

Visited out of network provider in an emergencySelected provider requested payment for covered servicesOthers

Description of illness or injury

Please include the following supporting documents in order to process the claims

Medical ReportsOriginal receipt of paymentOthers

Email Address

Phone Number

Total Amount Claimed

A/C Number

Account Name

Bank Name

Attach Supporting Document

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