What is the Optimize case number? Be sure to include WAL or SCA prefix.
Name of person to receive case coverage payment
Name
Date of Case
-
Month
-
Day
Year
Date
Was it Recon or a sideline? If a sideline, please list the sideline (Arthosurface, Sanara, etc)
Is a FEE ($200) or % case?
200
%
Notes: Like if the case coverage payment to be split with anyone?
Your Email - Jot will email a confirmation to this address
example@example.com
Submit
Should be Empty: