Provident Claims Services, Inc.

PO Box 38295

Pittsburgh, PA 15238-8295

Phone: 800.478.1752 | Fax: 412.963.0148

Email: claims@providentclaims.com

 

Business Hours: 8:30 AM to 5 PM

Please note, this document could take up to 15+ minutes to complete. If you wish to start filling it out now, you can always press "Save & Continue Later" at the bottom of this form to complete and submit at a later time. 

Review our Important Notice Regarding Fraud before continuing:

Provide name, address, and telephone # for usual family physician:

Provide name, address, and telephone # of physician that diagnosed your cancer or related conditions:

Provide name, address, and telephone # of physician that is currently treating your cancer or related conditions:

Provide name, address, and telephone # for all hospitals where you have received treatment for your cancer or related conditions:

I CERTIFY THAT THE ABOVE ANSWERS ARE TRUE AND COMPLETE ACCORDING TO THE BEST OF MY KNOWLEDGE AND BELIEF. I, the undersigned authorize any hospital or other medical-care institution, physician or other medical professional, pharmacy, Insurance support organization, governmental agency, group policyholder, Insurance company, association, employer or benefit plan administrator to furnish to the Insurance Company named above or its representatives, any and all information with respect to any injury or sickness suffered by, the medical history of, or any consultation, prescription or treatment provided to, the person whose death, injury, sickness or loss is the basis of claim and copies of all of that person's hospital or medical records, including information relating to mental illness and use of drugs and alcohol, to determine eligibility for benefit payments under the Policy Number identified above. I authorize the policyholder, employer or benefit plan administrator to provide the Insurance Company named above with financial and employment-related information. I understand that this authorization is valid for the term of coverage of the Policy identified above and that a copy of this authorization shall be considered as valid as the original. I agree that a photographic copy of this Authorization shall be as valid as the original. I understand that I or my authorized representative may request a copy of this authorization. I understand that I or my authorized representative may revoke this authorization at any time by providing the insurance company with written notification as to my intent to revoke.

THE AUTHORIZATION INCLUDED WITH THIS FORM MUST BE SIGNED AND SUBMITTED TO PROVIDENT CLAIMS SERVICES, INC.

A SMALL SECTION OF THIS FORM MUST BE COMPLETED BY AN AUTHORIZED OFFICER OF THE FIRE DEPARTMENT, RESCUE OR AMBULANCE SQUAD. IT MUST BE COMPLETED BY AN OFFICER OF THE NAMED INSURED (MUST BE SOMEONE OTHER THAN THE CLAIMANT OR CLAIMAINT'S FAMILY MEMBER). PLEASE PROVIDE US AN AUTHORIZED OFFICER'S CONTACT INFORMATION BELOW.

PROVIDENT WILL SEND THIS FORM TO THE OFFICER LISTED BELOW SO THEY CAN REVIEW, AUTHORIZE, AND SIGN THIS FIRST NOTICE OF CLAIM FOR COMPLETION. YOU WILL RECIEVE A FULLY EXECUTED COPY OF THE FORM FOR YOUR RECORDS AFTER THE OFFICER COMPLETES IT. 

See Important Notice Regarding Fraud in the PDF at the beginning of this form. 

Failure to complete this form in its entirety may result in a delay of processing your claim. 

I authorize any health care provider including, but not limited to, any health care professional, hospital, clinic, laboratory, pharmacy or other medically related facility or service; health plan; rehabilitation professional; vocational evaluator; insurance company; reinsurer; insurance service provider; third party administrator; producer; the Medical Information Bureau; GENEX Services, Inc.; the Association of Life Insurance Companies, which operates the Health Claims Index and the Disability Income Record System; government organization; and employer that has information about my health, financial or credit history, earnings, employment history, or other insurance claims and benefits including Social Security benefits, to disclose any and all of this information to persons who administer claims for Provident. Information about my health may relate to any disorder of the immune system including, but not limited to, HIV and AIDS; use of drugs and alcohol; and mental and physical history, condition, advice or treatment, but does not include psychotherapy notes.

I understand that any information Provident obtains pursuant to this authorization will be used to evaluate and administer my claim(s) for benefits, including any assistance in my return to work. I further understand that the information is subject to redisclosure and might not be protected by certain federal regulations governing the privacy of health information.

This authorization is valid for two (2) years from the date below, or the duration of my claim, whichever is shorter. A photographic or electronic copy of this authorization is as valid as the original. I understand I am entitled to receive a copy of this authorization.

I may revoke this authorization in writing at any time except to the extent Provident has relied on the authorization prior to notice of revocation or has a legal right to contest a claim under the policy or the policy itself. I understand if I revoke this authorization, Provident may not be able to evaluate or administer my claim(s) and this may be the basis for denying my claim(s). I may revoke this authorization by sending written notice to the address above. I understand if I do not sign this authorization or if I alter its content in any way, Provident may not be able to evaluate or administer my claim(s) and this may be the basis for denying my claim(s).

I authorize any physician, medical professional, hospital, covered entity as defined under HIPAA, insurer or other organization or person having any records, dates or information concerning the claimant to disclose when requested to do so, all information with respect to any injury, policy coverage, medical history, consultation, prescription or treatment, and copies of all hospital or medical records or all such records in their entirety to Provident Claims Services, Inc., on behalf of AXIS Insurance Company or its designated administrator. This authorization shall remain valid for a period of two years from the date signed. A photo static copy of this authorization shall be considered as effective and valid as the original. A copy of the authorization is available upon request of the company.

Parts 1 and 2 must be completed to properly identify the records to be released:

I understand that this Authorization is valid for a period of two (2) years from the date of the signature, or the duration of my claim, whichever is shorter. A photographic or electronic copy of this authorization is as valid as the original. I understand that I am entitled to receive a copy of this authorization. I understand that once this information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations. I understand that I have the right to revoke this authorization at any time by sending a written request to the entity/person I authorized above to release information.

**THE USE OF AN AUTHORIZED REPRESENTATIVE IS ONLY APPLICABLE IF THE MEMBER IS UNABLE TO SIGN ON THEIR OWN BEHALF.**

As an authorized representative, I have uploaded the documentation granting this authority. Please refer to POA, Guardianship, or Estate documentation.