Get How To Complete This Medical Claim Form - Mhbp Home

Completing the How To Complete This Medical Claim Form online is essential for ensuring your claims are processed efficiently. This guide will provide you with step-by-step instructions to help you fill out the form accurately and completely.

Follow the steps to successfully complete your medical claim form.

1. Press the ‘Get Form’ button to access the form and open it in the editing tool.
2. Begin by filling out the Member section with your last name, first name, middle initial, and member ID number.
3. Complete the Patient Information section if the claim is for a qualified dependent. Include their last name, first name, middle initial, date of birth, relationship to you, and sex.
4. If the claim is due to an accident or work-related illness, complete the Accident Information section. Specify the date of the accident, location, employment-related status, a description of the incident, and the date the patient first consulted a physician.
5. If the patient is eligible for Medicare, fill out the Medicare Information section and attach a copy of the Explanation of Benefits statement from your Medicare insurance carrier.
6. If there is other health insurance coverage, answer accordingly and fill in the necessary details, including the name of the policyholder, policy number, and insurance company contact information.
7. In the Authorization/Release of Information section, sign and date to authorize the Plan to obtain necessary information for claims processing.
8. In the Assignment of Benefits section, also sign and date to authorize direct payment to the provider if applicable.
9. If required, attach additional documentation such as a detailed statement from the provider and ensure all necessary fields are filled out.
10. Review the completed form for accuracy, save any changes, and download or print a copy for your records before submitting it to the provided mailing address.

Complete your medical claim form online today to ensure prompt processing of your claims.