Get Lc 7377 1 Form

The Lc 7377 1 Form is essential for submitting a claim for short-term recovery benefits. This guide will provide you with step-by-step instructions to conveniently fill out the form online, ensuring your information is accurately gathered and submitted.

Follow the steps to successfully complete the Lc 7377 1 Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin filling in the insured member's information at the top of the form. This includes the certificate number, insured's name, birth date, sex, address (including street, city, state, and zip code), email address, and personal cell telephone number. Make sure this section is completed accurately.
3. Indicate your authorization to leave confidential medical and benefit information on your personal cell phone by selecting ‘Yes’ or ‘No’. Provide your signature along with the date.
4. Specify the relationship of the claimant if it is not the primary insured and provide necessary details of the patient if applicable, including their name and birth date.
5. Describe the nature of the injury or sickness that requires hospital confinement or outpatient surgery. Include details about how and where the injury occurred, along with relevant dates.
6. For claims involving eligible dependents, fill in their insurance effective date. Ensure to also specify the periods of hospital care for which benefits are being claimed.
7. Collect and list all physicians and facilities that have been consulted or where treatment was provided during the six months prior to confinement. Include their names, addresses, phone numbers, and treatment periods.
8. Provide detailed information about the recovery services received, specifically indicating the type of skilled nursing or therapy services obtained, and attach any supporting documentation as required.
9. Review the form carefully to ensure all information is correct, clear, and complete. Make sure to read the crucial notices pertinent to your state before signing.
10. Finally, save changes to the form, download it for your records, and print or share the completed form as needed. Ensure to attach any required documentation, including the authorization to release medical information form before submission.

Start filling out your Lc 7377 1 Form online now to ensure you submit your claim promptly.