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  Information Required: Medical Expense Claim Form
The above form is to be used to submit health claims. Please refer to the instructions below in completing this form:
Identifying Information
The top section of the form must be completed in full in order that we may identify you as an Insured Person. If you do not know your Policy Number please contact your employer.
Question 1: Please indicate of there are benefits available under any other plan including spouses insurance or government health plan.
Question 2: Provide details of accident, if applicable.
Question 3: List all services including dates and the diagnosis for each.
Question 4: Advise if you have had this or a similar condition. Advise when and describe.
*Note: All questions must be answered in order to avoid delay in the processing of your claim.
Authorization:
The last section is the authorization. The claimant is required to sign this in order that we may obtain information required to process his/her claim.
Attach all original receipts and keep copies for your records. If you have received partial payment from another source attach copies of bills along with the statement of benefits paid from the other provider.
Claim should be submitted to the address indicated on the top left hand side of the claim form. |
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