Claims Form

Regional Care Claims Form

(Not For FSA/HSA/HRA/DCAP)

Please attach a super bill from your Provider or other documentation as proof of the services. Documentation MUST include procedure and diagnosis.

Patient Information
Full Name*

First NameLast Name
Birth Date*

MonthDayYear
Company*
ID Number or SSN*
E-mail*
Relationship to Employee:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Claim Information
Claim Type*
Description of Charges*

I certify that this information is complete and accurate and authorize release of medical information necessary to process this claim. A photocopy of this authorization shall be as valid as the original.

Patient Signature or Parent if Patient is a minor:*
Signature Date*

MonthDayYear

I hereby authorize payment of benefits directly to any providers of service, otherwise payable to me for services, but not to exceed the reasonable and customary charge for those services.

Patient Signature or Parent if Patient is a minor:
Signature Date

MonthDayYear
Select Files
File 1

Upload a File

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File 2

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File 3

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File 4

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If mailing this form, send the completed form to:
Regional Care, Inc., 905 West 27th Street, Scottsbluff, NE 69361
Fax - (308) 635-2018
For Customer Service, Please Call: (308) 635-2260 or (800)-795-7772

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