Get Abu-1193-executive (1003). Executive Option Claim Form - Piasc

This guide provides clear, step-by-step instructions on how to successfully complete the ABU-1193-EXECUTIVE (1003). Executive Option Claim Form - Piasc online. By following these guidelines, users can ensure that their claim is processed efficiently and accurately.

Follow the steps to fill out the form correctly.

1. Press the ‘Get Form’ button to access the claim form and open it in your preferred document editor.
2. Begin by filling in the 'Name of the insured' field with the full name of the individual who holds the insurance.
3. Enter the 'Phone number' for easy communication regarding the claim.
4. Provide the 'Mailing address' including the number, street, apartment (if applicable), city, state, and zip code.
5. Fill in the 'Name of patient' section with the name of the individual receiving the medical treatment.
6. Check the box if the above information represents a new address and phone number or a name change, and provide the previous name if applicable.
7. Input the 'Social Security No' and 'Policy number' associated with the claim.
8. Enter the 'Birthdate' of the insured individual in the specified month/day/year format.
9. Specify the 'Relationship' of the patient to the insured.
10. List the name of the base health plan, along with the claims office address and phone number.
11. Repeat the previous step for the base dental plan and vision plan, if applicable.
12. Ensure you are using a separate claim form for each dependent as specified in the form instructions.
13. Attach any necessary documentation, such as itemized billing statements, for expenses incurred while insured under PIBT.
14. Read and sign the authorization for disclosure of personal information and date your signature.
15. Once all sections are completed, save any changes to the document, and then download, print, or share the completed form as needed.

Complete your documents online today to ensure a smooth claims process.