Medical Claim Form

Medical Claim Form

Submit your medical claim by providing patient, insurance, provider, and claim details.
Patient Information
Patient Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Relationship to employee:
Is patient Employed?
If employed, employer name:
If full time Student, school name:
Employee Information
Name

First NameLast Name
SSN
DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Patient Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Status
Claim Information
Claim for:
Group Number
Is the condition work related?
Will or has a third party liability claim beenfiled?
Provider Information
Provider Name
Provider NPI (National Provider Identifier)
Provider Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Claim Details
Date of Service

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Description of Services
Amount Claimed (USD)
Describe illness or accident
If accident, when and where did it occur
Does patient have other health coverage?
If yes, what type?

Other
If yes above give name, address of other plan insurance carrier, HMO, Etc.
I certify that the information set forth in this claim form and any attachments is complete and accurate to the best of my information and belief. I authorize all appropriate persons or institutions to release to or obtain from the Plan administrator any information to process this claim. I agree to reimburse the Plan for any benefits paid on my behalf in the event that I or my dependent receives any monies which reimburses me for such expenses in whole or in part.
Signature
Should be Empty:

Medical Claim Form

Patient Information

Employee Information

Claim Information

Provider Information

Claim Details