Follow the steps to successfully complete your claim form.

1. Click ‘Get Form’ button to obtain the claim form and open it in your preferred editor.
2. Begin by entering the 'Patient Information' in Section A. Provide the patient's last name, first name, and check if they have other health insurance coverage. If applicable, list the name of the other insurance company, group number, and relationship to the participant.
3. In Section B, enter the participant's information as listed on their Writers Guild Industry Health Fund card. Include participant ID number, last name, first name, address, work phone number, date of birth, and sex.
4. Indicate whether the medical expense was due to an accident, whether it is job-related, and if you have filed for Worker’s Compensation. Provide the date of the accident or injury and the diagnosis ICD-9-CM code number, which must be obtained from the healthcare provider.
5. Proceed to Section C, where you will need to detail the medical information. Use a separate line for each charge and attach itemized bills. List the date of service, type of provider, place of service, description of service, number of days or units, and the total charges for each service.
6. If applicable, provide the referring provider's name, their tax identification number, and their contact information. You must also indicate if payment should be directed to the patient or provider by selecting the appropriate option.
7. Sign the form certifying that the information provided is complete and correct, authorizing the release of your medical information as necessary, and acknowledging the penalties for providing false information.
8. After completing the form, review all entered information to ensure accuracy. You can then save changes, download, print, or share the completed form as needed.

Take the first step towards submitting your health claim by filling out the form online today.