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E the processing of your claim. I. COMPLETE FOR ALL MEDICAL CLAIMS Employee Social Security Number Employee Name (Last, First, Middle) II. COMPLETE FOR DEPENDENT CLAIMS ONLY Dependent Name (Last, First, Middle) Relationship to Employee Disabled? A student and/or financially dependent on you? If claim is for dependent child over age 19 at the time the claim was incurred, was the dependent: (if B , see instruction number 5 on the reverse side of this form) Name of Spouse / Dependent with.

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Related content

Public Employees' Benefits Program - State of...
May 31, 2012 — HealthSCOPE Benefits. P.O. Box 91603. Lubbock, TX 79490-1603. Customer...
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Public Employees Benefits Program (PEBP) for the...
P.O. Box 91603. Lubbock, TX 79490-1603. Express Scripts P.O. Box 66566. St. Louis, MO...
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UNITEDHEALTH GROUP I UnitedHealth Group Incorporated (NYSE:UNH) acquired HealthSCOPE Benefits, Inc.

Q: Who is HealthSCOPE Benefits? A: HealthSCOPE Benefits is a claims administration and health management firm providing services to self-funded employers.

Healthscope has an overall rating of 2.9 out of 5, based on over 121 reviews left anonymously by employees.

HealthSCOPE Benefits SPRTN Customer Service 1-866-905-6146 .healthscopebenefits.com Access personal claim information, Plan SPDs, forms and general notices.

We support 270/270 transactions through Transunion & Passport.

HealthSCOPE Benefits was founded in 1985 as Burgett & Dietrich and specialized in developing managed care networks for Fortune 500 companies in non-metropolitan areas.

SUBMIT THIS COMPLETED FORM WITH REQUESTED DOCUMENTATION to: HealthSCOPE Benefits, Inc., P.O. Box 99006, Lubbock, TX 79490-9006.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232