Get Intellicare Reimbursement Form

Filling out the Intellicare Reimbursement Form online can be a straightforward process when guided properly. This guide provides a step-by-step breakdown to help users complete the form accurately and efficiently.

Follow the steps to complete the Intellicare Reimbursement Form online.

1. Press the ‘Get Form’ button to access the Intellicare Reimbursement Form and open it in the editor.
2. Begin with the general data of the deceased member section. Here, you will need to provide the full name of the deceased and, if applicable, their maiden name if they were a married woman.
3. Fill in the date and place of birth for the deceased, making sure to indicate the source of the birth date information.
4. Complete the residency details, including the deceased's residence at the time of death.
5. Next, provide details regarding the place and date of death, the cause of death, and the deceased’s age at the time of death.
6. Indicate the deceased's occupation at the time of death and the last date they attended work.
7. In the health history of the deceased section, document the date the deceased first showed symptoms of the last illness and when they first consulted a physician.
8. List the names and addresses of all physicians who treated the deceased during their last illness, along with the relevant dates of attendance or confinement.
9. Proceed to the data of the beneficiary-claimant. State your capacity for claiming this assistance and your relation to the deceased.
10. Provide your date of birth. If you are a married minor or surviving spouse, be sure to include your marriage certificate.
11. Sign and date the declaration at the end of the form to confirm your claim for internment assistance, including witness signatures as required.
12. Finally, review all completed sections for accuracy. Save any changes, and choose to download, print, or share the form as needed.

Ensure your reimbursement claims are processed quickly by completing the Intellicare Reimbursement Form online today!