MEMBER MEDICAL CLAIM SUBMISSION

MEMBER MEDICAL CLAIM SUBMISSION
To be considered a valid claim, submit your receipt and itemized statement / superbill, along with this completed claim form.

If sufficient documentation is not received, the claim will not be processed.

Claim submission information must include procedure codes and diagnosis codes.
Personal Information
Employer Name:*
Group ID Number:*
(From ID Card)
Employee Name:*

First NameLast Name
Employee Member ID:*
(From ID Card)
Employee Phone Number:

Area CodePhone Number
Employee Email Address:*
username@domain.com
Name of Patient:*

First NameLast Name
Patient's Member ID:
(If other than Employee)
Patient DOB:

MonthDayYear
Date of Birth
Provider Information
Issue payment to: (if applicable)*

MemberProvider
Facility Name:*
Provider TIN/NPI:*
Tax ID or NPI
Provider Name:*
Provider Address: *

Physical/Street Address (Where services were rendered)

Street Address Line 2

CityState

Zip Code
Type of Service:*

MedicalDentalVisionPrescription
Description of Charges:*
Attach complete Documentation

Browse Files
Receipts/Itemized Statements/Superbills Cancelof
This information is accurate and authorize the release of medicalinformation necessary to process the claim.*

I Understand
A photocopy of this authorization shall be as valid as the original.*

I Understand
Not all services may be covered under my plan.*

I Understand
Signature*
Patient Signature (Parent/Guardian if Patient is a minor)
Date*

MonthDayYear
Email or Fax completed Claim Form and documentation to:

rci-customerservice@regionalcare.com

Fax (308) 635-2018

For Customer Service, call 1-800-795-7772 or (308) 635-2260
Should be Empty:

MEMBER MEDICAL CLAIM SUBMISSION

Claim submission information must include procedure codes and diagnosis codes.

Personal Information

Provider Information

Email or Fax completed Claim Form and documentation to:

rci-customerservice@regionalcare.com

Fax (308) 635-2018

For Customer Service, call 1-800-795-7772 or (308) 635-2260