Get Claimant S Statement And Authorization -

Filling out the claimant's statement and authorization form is an essential step in processing your claim efficiently. This comprehensive guide will provide you with clear instructions to navigate each section of the form online, ensuring you complete it accurately.

Follow the steps to fill out the form successfully.

1. Press the ‘Get Form’ button to obtain the form and open it in the editing interface.
2. Begin with Part A, which is necessary for all claims. Enter the insured name and the claimant's name (the patient) carefully, along with their sex, home and work telephone numbers, fax number, and email address. Ensure that the birthdate and plan number are correctly filled in.
3. For the mailing address, include the full street address, city, state, country, and postal code. Also, complete the citizenship and home country information for the claimant. If applicable, note the country visited and be prepared to provide a passport copy if requested.
4. Indicate if the claimant is a full-time student or employed, and if so, provide the name and address of the school or employer, respectively. Answer whether there are any additional insurance coverages that could help with hospital and medical expenses, providing details if necessary.
5. Proceed to Part B, which is specifically for new claims. Describe how the condition began, providing a detailed account of symptoms, and specify when the first symptoms occurred, including the exact date if possible.
6. Indicate if the claimant has previously had treatment for the same condition, noting the attending physician's details if applicable. Include the family physician's information too.
7. List any ailments or conditions experienced in the last five years, with dates and attending physician contact details. This comprehensive information can assist in the claims process.
8. Complete Part C, where you verify the accuracy of the information provided and authorize the release of this information to HCC Medical Insurance Services. Sign and print your name and the date, as well as the patient's signature and details.
9. Also, authorize the assignment of benefits to the appropriate medical provider by signing the relevant section.
10. Finally, review all information for completeness. Save any changes made to the document. You can then download, print, or share the form as needed.

Prepare to submit your documents online to ensure your claim is processed promptly.