Provident Claims Services, Inc.

PO Box 38295

Pittsburgh, PA 15238-8295

Phone: 800.478.1752 | Fax: 412.963.0148

Email: claims@providentclaims.com

Website: 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 primary care physician:

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 UNDER FLORIDA LAW, MEDICAL AND HEALTH INFORMATION IS PRIVILEGED AND CONFIDENTIAL AND MAY NOT BE RELEASED TO ME OR TO OTHERS WITHOUT MY EXPRESS AND INFORMED CONSENT. FURTHER, I UNDERSTAND THE INSURANCE POLICY FOR WHICH THIS CLAIM IS BEING SUBMITTED HAS BEEN PURCHASED BY THE EMPLOYER TO ASSIST WITH THE EMPLOYER'S COMPLIANCE WITH FLORIDA STATUTORY REQUIREMENTS RELATING TO FIREFIGHTER CANCER BENEFITS. IN ACCORDANCE THEREWITH, I HEREBY AUTHORIZE AND CONSENT TO THE RELEASE TO THE EMPLOYER, ITS ATTORNEYS, AND ITS INSURANCE AGENT OR BROKER REPRESENTATIVES FOR THE APPLICABLE INSURANCE POLICY, ANY AND ALL INFORMATION, DOCUMENTATION, AND CORRESPONDENCE THAT PROVIDENT CLAIMS SERVICES, INC. MAY UTILIZE OR OBTAIN RELATING TO THIS CLAIM.

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 OR ELECTRONIC 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 REPRESENTATIVE OF THE FIRE DEPARTMENT OR MUNICIPALITY. THE INDIVIDUAL COMPLETING THIS SECTION MUST BE AN OFFICIAL OF THE NAMED INSURED AND MAY NOT BE THE CLAIMANT OR A MEMBER OF THE CLAIMANT'S IMMEDIATE FAMILY. PLEASE PROVIDE US AN AUTHORIZED OFFICER'S CONTACT INFORMATION IN THE FIELDS 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; re-insurer; 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 PCS. 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 PCS 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 re-disclosure 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 PCS 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, PCS 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, PCS 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.

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. 

Authorization Agreement (ACH Direct Deposit Only). By signing below, I (the "Receiver") authorize Provident Claims Services, Inc. (PCS) (the "Originator") to initiate Automated Clearing House (ACH) credit entries (direct deposits) to the deposit account identified below (the "Account"). This authorization is limited to the direct deposit of claim payment proceeds and any permissible correcting entries related to those deposits.

This form is to be used for PCS direct deposit of funds only.

No Liability for Bank Delays/Incorrect Information. I understand the Originator is not responsible for delays or losses caused by incorrect or incomplete information I provide, actions or errors by my financial institution, or events outside the Originator's reasonable control.

Compliance and Dispute Cooperation. Entries initiated under this authorization will comply with the Nacha Operating Rules and applicable U.S. law. I certify that I am an authorized signer or owner of the Account and authorize my financial institution to provide information needed to resolve any entry, return, or notice of change related to this authorization.

Revocation/Changes. This authorization will remain in effect until the Originator receives my written notice to change or revoke it. Any change or revocation request must be received at least five (5) banking days before the next scheduled deposit date to allow a reasonable opportunity to act.

Notice of Issues. I will promptly review my Account activity and notify PCS if a direct deposit has not been received or if an amount is incorrect. To the extent permitted by law and the Nacha Rules, claims relating to an unauthorized or erroneous entry are subject to applicable reporting timeframes.

Correction, Reversal, and Adjustments for Errors. If an entry is made in error (including an incorrect amount, duplicate entry, wrong account, or wrong effective date), I authorize the Originator to initiate a correcting entry or reversal as permitted by the Nacha Operating Rules and applicable law. The Originator will make reasonable efforts to notify me of any reversal and the reason for it as required by the Nacha Rules.

Account Verification and Receipt of Entries. I authorize the Originator and its financial institution to verify my Account information, including by initiating one or more prenotification (zero-dollar) entries or other commercially reasonable verification methods, and to deposit funds to the Account in accordance with this authorization.

Privacy and Data Use Notice. PCS will use the banking and personal information provided on this form solely for the purpose of initiating and administering ACH direct deposit transactions and for related operational, legal, and compliance purposes. Such information will be maintained and safeguarded in accordance with applicable federal and state privacy and data security laws, including the Gramm-Leach-Bliley Act (GLBA), and will not be disclosed to third parties except as necessary to process ACH transactions, comply with law, or as otherwise permitted by applicable regulations.