HPR Medical Claim Form

Part 3 - Accident / Injury Information
Was care required because of an injury?*

YesNo
Did the accident occur while at work?*

YesNo
Date Injured*

MonthDayYear
Describe how the injury occurred*
Was the claim filed with Workers' Compensation?*

YesNo
Workers' Compensation Claim Number*
Upload Workers' Compensation Award Letter or Controversion Letter*

Cancelof
Are you authorizing us to issue payment directly to the provider?*

YesNo
AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN

I hereby authorize payment directly to the Physician of the Surgical and/or Medical Benefits, if any, otherwise payable to me for his or her services but not to exceed the reasonable and for those services. Do not sign if bills have been paid.
Employee Signature*

Clear
Date*

MonthDayYear
I hereby certify that the foregoing statements, including any accompanying statements, are true and correct and complete to the best of my knowledge, and hereby further authorize my attending physician, practitioner or hospital in which confinement took place to furnish and disclose all facts concerning my physical condition that are within their knowledge. A photocopy customary charge of this authorization is as valid as the original.
Patient Signature (Employee/Parent, if patient is a minor)*

Clear
Employee Signature*

Clear
Date*

MonthDayYear
To ensure prompt payment submit only itemized bills. An itemized bill is the actual bill from the provider showing: a) provider name and address; b) date of service; c) diagnosis; d) procedure done and e) cost of each procedure. A “balance due” or non-itemized bill is NOT acceptable.

Note: Separate forms are required to be completed for each patient.
Upload Itemized Bill*

Cancelof
Fund ID
Should be Empty:

Heating, Piping and Refrigeration Medical Fund

PART 1 – EMPLOYEE INFORMATION

Part 2 - Insurance Information

Part 3 - Accident / Injury Information