Send Us a Claim

A Direct Line for Details.

To submit a claim referral or invoice for negotiation, please fill out the form below.

Always feel free to contact us at:

Email: admin@incingo.net
Phone: 844-631-8709
Fax: 844-331-5840
112 S. Main St. Suite A. Ann Arbor, MI 48104

*Required Information

Patient Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Patient Phone*
Claim #*
Date of Birth*
Month
Day
Year
Date of Injury*
Month
Day
Year
ICD-10 Code(s)*
Separate multiple codes with commas.
Attachment(s)
Demographics / Prescriptions / Invoice for Negotiation
Max. file size: 80 MB.
How can Incingo Help?*
Your Name*
First Last
Your Email*
Your Phone*