• Submit a case by fax

    Fax Submission & Payment

    Use this option if you have completed a paper or PDF version of the Case Management Request Form and would like to submit it by fax.

    Step 1 - Fax the Case Management Requset Form

    Fax the completed Case Management Request Form to:

    • Fax: (469) 599-7188

    Step 2 - Submit Payment to Initiate the Case

    After faxing the form, remit the $250 Case Initiation Fee using the payment link below. Payment may be made by credit card, debit card, or ACH.

    Important:
    Enter the Case Number from the Case Management Request Form during checkout to ensure your payment is correctly applied to the associated request.

    Step 3 - We'll Take It From Here

    Once both the completed form and payment are received, BioConnetiX will initiate case coordination in accordance with the authorized scope and provide updates as services are coordinated.

    Need a form?

    Download a PDF version here
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