Get Healthkeepers Member Claim Form (hmo Only) - Anthem

Filing a claim can be a straightforward process when you have the right guidance. This guide will walk you through each section of the HealthKeepers Member Claim Form, ensuring you have the necessary information to complete it accurately and efficiently.

Follow the steps to fill out the form accurately and efficiently.

1. Press the ‘Get Form’ button to access the HealthKeepers Member Claim Form and open it for editing.
2. Begin by entering the patient information in Section 1. This includes the patient's last name, first name, middle initial, date of birth, address, and member ID number.
3. Indicate the patient's relationship to the member, selecting either self, spouse, or child as applicable.
4. Provide details regarding the patient's gender, and if applicable, the date of the injury, if treatment was required due to an injury.
5. Complete the questions regarding the nature of the treatment: Was it for an illness or injury? Was the condition related to employment or an auto accident?
6. Ensure you include the diagnosis or symptoms you've experienced. If the patient has other insurance coverage, provide the necessary details in the following fields.
7. You must also confirm if you have paid for the itemized services. If yes, specify the type of policy and include relevant information about the other insurance provider.
8. Sign and date the form in the certification section to verify the accuracy of the provided information.
9. Move to Section 2 to provide the provider information. Fill in the provider's last name, first name, address, professional license number, and IRS Tax ID or social security number.
10. In Section 3, the policyholder must sign and date the form to acknowledge the claim.
11. Once all sections are completed, you may save the changes, download, print, or share the completed form as required.

Submit your completed claims form online to ensure timely processing.