Follow the steps to complete your claim form online.

1. Click ‘Get Form’ button to obtain the claim form and open it in your preferred online editor.
2. Begin by filling out the Statement of Insured section. Enter your full name, policy number, and Social Security number. Provide your address, including city, state, and zip code.
3. Next, input the patient's information, including their name, relationship to you, and date of birth. Ensure all details are accurate to prevent processing delays.
4. Describe the injury or sickness fully. If applicable, include how the accident occurred, the date of the injury or the start of sickness, and the date you first received treatment.
5. List the name and address of the physician who first treated the condition. Ensure this information is complete and correct.
6. Indicate whether the injury or sickness is due to employment and if you will file for workers’ compensation. Also, specify if you or your dependent have coverage under any other insurance plan.
7. If there is additional insurance, provide the name of the carrier, policy number, daily benefit amount, and coverage type. Include any termination details as requested.
8. Lastly, review the certification statement and add your signature. Include the date of signing as well.
9. Complete the authorization on the reverse side of the form, signing where required, and specifying any personal representative’s authority if applicable.
10. Once all the sections are filled out, save your changes, download a copy for your records, print the completed form, and share it with the necessary parties as needed.

Complete your Fidelity Hospital Confinement Claim Form online today to ensure your claims are filed accurately.