PLEASE READ THIS BEFORE USING THIS FORM: Please type directly on this form then click the "Preview Data" button at the bottom. You will have the chance to review and change your entered data before submitting the form. Upon submission, your information will immediately be e-mailed to PCA and you will promptly be sent a confirmation e-mail with all data which can easily be printed out, or copied and pasted into your electronic claim file.
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TIP - Use the TAB key to move to next field - SHIFT TAB to go back to previous field NEW TIP
- Use the DOWN arrow key in a field to bring up data previously entered.
(Please be careful using this feature - it is easy to select wrong data.) If this doesn't seem to work for you and you are using Internet Explorer, click on the "Tools" menu on the top toolbar. Then select "Internet Options", then choose the "Content" tab. Click on the "Auto Complete" button, then make sure "Forms" has a checkmark next to it. There is also a "clear forms" button on the "Content" tab to use if you want to clear out previous data and start fresh. If you are unable to change your settings, please see your system administrator.