Get Hospital Indemnity Claim Form Filing Instructions - Utah Health ...

Completing the Hospital Indemnity Claim Form is an important step in securing your claims through Utah Health. This guide will provide you with clear, step-by-step instructions to ensure that you fill out the form accurately and effectively, helping you navigate the process with confidence.

Follow the steps to complete your claim form online.

1. Press the ‘Get Form’ button to access the Hospital Indemnity Claim Form. This will open the necessary form in your online editor for completion.
2. Begin with the Insured's Statement of Claim section. Fill in the name of the insured, policy number, street address, city, state, ZIP code, telephone number, and date of birth. Ensure all information is accurate to prevent processing delays.
3. Next, include the claimant's details. Input the claimant's name, relationship to the insured, and their date of birth. This ensures the claim is properly associated with the right individual.
4. Document the illness or injury that is prompting the claim. Provide a detailed account of the illness, including the date it was diagnosed or the accident date if applicable.
5. Describe the onset and nature of the illness or details regarding the accident in the designated section. Be specific to aid in the assessment of the claim.
6. Indicate the date you were first treated for your illness or injury. List the name of the hospital and the treating doctor, along with their contact information.
7. Address whether you have had a similar condition in the past by selecting 'Yes' or 'No.' This informs the insurer of any pre-existing conditions.
8. Complete the authorization section for the use and disclosure of protected health information as outlined in the corresponding form section. This is necessary for insurance processing.
9. If within the first 12 months of the policy, list all physicians who have treated the patient within that timeframe, along with their contact details and diagnosis.
10. Finally, review all completed fields for accuracy and sign the document. After signing, either save changes, download, print, or share the form as necessary.

Start filling out your Hospital Indemnity Claim Form online today to ensure your medical claims are processed efficiently.