Get Medical Claim Form - Trusteed Plans

Filling out the Medical Claim Form - Trusteed Plans online is a straightforward process that ensures your claims are accurately processed. This guide will walk you through each section of the form so that you can efficiently complete it.

Follow the steps to accurately complete your medical claim form.

1. Click the ‘Get Form’ button to access the Medical Claim Form - Trusteed Plans and open it for completion.
2. Begin with the Employee Statement section. Fill in your last name, first name, and middle initial. If your address has changed, mark the checkbox for 'new address.' Include your date of hire, birthdate, telephone number, and social security number. Provide the name of your employer, your group number, and your marital status.
3. Indicate whether the coverage for this claim is provided by another insurance or plan by selecting 'yes' or 'no.' If 'yes,' provide the insurance company's name and address along with the policy number.
4. Fill in the patient's name, sex, and date of birth. Specify their relationship to you and indicate if you have legal custody for a dependent child. If the child is over 18, specify if they are a full-time student and your dependency on them for child support.
5. Input details about the diagnosis, the nature of the illness or injury, and the date of any accident that may have occurred. State whether the condition is related to employment.
6. Provide the details of the first physician consulted for the illness or injury, including their name and the date of the first visit. If applicable, complete the authorization statements for benefits and ensure you sign and date them.
7. In the Attending Physician’s Statement section, make sure the physician completes all questions regarding the patient's condition, treatment details, and charges associated with the care provided.
8. Once all sections of the form are completed, attach all itemized bills and statements to the form.
9. Finally, review your completed form for accuracy, save your changes, and choose to download, print, or share the form as needed.

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