Get Transconnect Claim Form

Filling out the Transconnect Claim Form online is a straightforward process that ensures your claim is submitted accurately and efficiently. This guide will walk you through each section of the form, providing clear instructions to assist you in completing it correctly.

Follow the steps to expertly complete the Transconnect Claim Form online.

1. Click 'Get Form' button to access the Transconnect Claim Form and open it in your preferred editor.
2. In Section 1, enter the employee's information. Fill in the insured's full name, date of birth, certificate number or social security number, address including city, state, and ZIP code, phone number, group number, marital status, and gender. Make sure all details are accurate.
3. Proceed to Section 2, where you will provide patient information. Enter the patient’s full name, date of birth, and relationship to the employee. If applicable, include the date of the accident, the patient's role in the accident, whether it is covered by Workers’ Compensation, date of service, place of service, description of the service performed, and reason for the visit.
4. If required, complete Section 3, which is the attending physician's statement. This section must be filled out by the physician if there is no itemized bill. Ensure the physician's signature, date, and diagnosis are included, and provide any specific medical codes as necessary.
5. Review all sections carefully to make sure all information is correct and complete. Missing or incorrect information may delay processing your claim.
6. Once you have filled out the form, save your changes. You can then download, print, or share the completed form as needed for submission.

Complete your claim documents online today to ensure timely processing of your request.