Get International Claim Form.doc

Filling out the international claim form can seem daunting, but with clear instructions, it becomes manageable. This guide aims to assist you in completing the form accurately so that your claims can be processed without delay.

Follow the steps to fill out the form seamlessly.

1. Click 'Get Form' button to obtain the form and open it in your browser.
2. In Part A, provide the employee's name, including their middle, first, and last names. Include the employer's name and group policy number, along with the mailing address, city, state, and postal code. Lastly, indicate whether this is a permanent change of address and the employee's status.
3. In Part B, fill in the patient's name and gender, their relationship to the employee, and whether they have any other form of medical or dental coverage.
4. In Part C, describe the diagnosis or chief complaint. Indicate if the condition is due to an employment-related injury.
5. In Part D, indicate your payment preference: whether to receive a check, wire transfer, or have payment made directly to the provider. If opting for a wire transfer, ensure you enroll as instructed on the form.
6. In Part E, provide authorization to release or obtain information. Sign the form, ensuring all details are accurate to the best of your knowledge.
7. Once all sections are completed, review the form for any errors. You can save your changes, download, print, or share the completed form as needed.

Submit your completed claim form online and ensure you have all necessary documentation ready for processing.