Type of treatment received: Check only one type and attach itemized statements. Please use a separate claim form for each different type of treatment.

Download a claim form for medical services, pharmacy services or overseas care. Medical Forms Health Benefits Claim Form

Type of treatment received: Check only one type and attach itemized statements. Please use a separate claim form for each different type of treatment. Please ...

Attached receipts must include procedure codes and diagnosis codes, such as CPT/Dx code as well as tax ID and individual cost for each service/name of the ...

Instructions for Submitting Claims. 1. Submit a claim only when you are billed for services from a provider that does not directly submit a claim to the ...

Please attach receipts and medical records (test results, x-rays, etc.), if available. • Please keep photocopies of all documentation for your personal records.

Use this form to file a claim when your doctor doesn't file the claim for you. You should send this completed claim form as soon as possible after you get care.

MEDICAL CLAIM FORM. (Instructions for filing on second page). PARTICIPANT'S NAME (Last, First, M.I.). MEMBER ID NUMBER. HOME ADDRESS (Street, City, State, Zip).

HOW TO FILE A CLAIM. Items 1 through 12 of the top portion of the claim form must be filled out by you. The doctor, hospital or other supplier may complete.

Use this claim form to submit eligible pharmacy expenses for reimbursement. You have to submit one claim form for each person and each prescription.