DFY Intake — Claim Maximizer

SECTION 01

About you

How we contact you with status updates and questions.

Full name *

Email *

Phone (optional)

For quick clarifying questions only. Status updates go by email.

State of residence *

SECTION 02

About the bill

The basics — what, where, when, and how much.

Hospital or provider name *

Date of service *

Account / invoice number

Optional — helps speed things up.

Total billed ($) *

The chargemaster number on the bill.

You're being asked to pay ($) *

Patient responsibility. Must be $1,500+ for DFY.

Has the bill been referred to collections? *

No Yes Not sure

Is this bill currently in active litigation? *

No Yes — they've sued me

If yes, this is outside DFY scope — we'll route you to an attorney and refund.

SECTION 04

Financial situation

For 501(r) charity-care eligibility check (nonprofit hospitals only). Stays confidential — used only to apply for charity care on your behalf if eligible.

Household size *

Annual household income *

Range only. Used to check 501(r) eligibility (cutoff is typically 400% FPL).

SECTION 05

Documentation

After you submit, please email a photo or PDF of your bill (and EOB if you have it) to hello@claimsmaximizer.com with your case ID. We'll send you the case ID right after submit.

Do you have an itemized bill yet?

Yes, have it Only summary bill No bill yet

If you only have a summary bill, our first action is to request the itemized version under HIPAA § 164.524.

Anything else we should know?

SECTION 06

Authorization

Required so we can communicate with the hospital on your behalf. Limited scope — never financial.

I authorize Claim Maximizer to communicate with the hospital and any related billing entities on my behalf in connection with the bill described above. This authorization includes:

Requesting itemized billing records under HIPAA § 164.524
Sending dispute and negotiation letters in my name
Applying for 501(r) charity care if I'm income-eligible
Filing complaints with CMS, my state insurance commissioner, or my state attorney general if escalation is needed

This authorization does not permit Claim Maximizer to make payments on my behalf or to settle the account without my explicit approval. I retain full authority over any final settlement decision. I may revoke this authorization at any time by emailing hello@claimsmaximizer.com.

I have read and agree to the authorization above. *

Type your full name to sign *

Must match the name in Section 1.

Date

After submit, your case ID arrives within 60 seconds. We start work within one business day.

Got it — case received.

Your case ID is —. You'll see this on every email about your case.

What happens next:

Within 60 seconds: confirmation email with your case ID and next steps
Within 24 hours: we email you a brief "intake review" confirming we have what we need (or asking for the bill photo if we don't)
Within 1 business day: first letter goes out via certified mail
Weekly: status update emails through resolution

Action item for you: Email a photo or PDF of your bill (and EOB if you have it) to hello@claimsmaximizer.com with your case ID in the subject line. That's the only thing on your plate from here.

← Back to Claim Maximizer