• Heating, Piping and Refrigeration Medical Fund

    Physical Address: 8700 Ashwood Dr. Suite 150, Capitol Heights, MD 20743 • Mailing Address: PO Box 34567 Seattle, WA 98124
    Phone: (410) 444-3756 or (800) 618-2879 • Fax: (206) 441-9110 • Website: HPRBenefitFunds.com

    Administered by
    Welfare & Pension Administration Service, Inc.

  • PART 1 – EMPLOYEE INFORMATION

  • Gender*
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Employee Marital Status*
  • Patient Gender*
  • Patient Date of Birth*
     - -
  • Relation to Employee*
  • If claim is for a dependent child, please indicate their relationship to you*
  • If dependent child is age 19 or older, does he/she have access to insurance through his/her employment*
  • If yes, was coverage declined?*
  • If dependent child is age 26 or older, does child have a developmental disability or physical handicap?*
  • Spouse Birth Date*
     - -
  • Is the Member's spouse employed?*

  • Part 2 - Insurance Information

  • Are you or your dependents covered under another group insurance plan or Medicare?*
  • Which insurance is your Primary Insurance*
  • Which insurance is your Primary Insurance*
  • Other Group Plan Covers*
  • Other Group Plan Includes*
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  • Do you or dependents Medicare Part A or B?*
  • Medicare A Effective Date*
     - -
  • Medicare B Effective Date*
     - -
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  • Part 3 - Accident / Injury Information

  • Was care required because of an injury?*
  • Did the accident occur while at work?*
  • Date Injured*
     / /
  • Was the claim filed with Workers' Compensation?*
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  • Are you authorizing us to issue payment directly to the provider?*

  • 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.

  • Date*
     - -

  • 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.

  • Date*
     - -

  • 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.

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