Finance Response Form

You are the recipient of a notice regarding unclaimed funds/uncashed checks. Use this form to request replacement checks. If any checks listed on your notice are not due to you, return the completed notice via mail with a detailed explanation (and any applicable documents) so that the check(s) may be cancelled. Please be sure to complete all required fields. Do not respond multiple times as this will delay processing of the replacement check(s). When responding online, do not mail in your letter. Keep it for your records. If your submission does not contain all required information, you will receive correspondence via mail from us.

 

To ensure proper completion, please review our FAQs.

  1. Stale Date Form Information
  2. Checks Issued
  3. Multi Check Panel
  4. Contact Information
  5. Last Panel
  6. Submit Panel

Stale-checks@elevancehealth.com

Stale Date Response Finance Form

Requestor Information

All fields are required, unless marked optional.

Payee name should be entered exactly as shown on letter.

Date of birth must be lesser than current date

If other, please complete the notice you received and submit it via mail. Your request cannot be processed if the notice is not signed.

Check(s) to be Reissued

Delete this check

Please provide account and check information before adding more checks.

+ Click here to add more checks(maximum of 8 checks) If there is more than 8 checks, Please submit another form.

Contact Information

Confirmation Email Address is not matching with Email Address

Electronic Signature

Date must be current date