Follow the steps to successfully complete your form online.

1. Click the ‘Get Form’ button to access the form, making it available for you to complete in the provided editor.
2. Begin with Part A titled 'Member Statement'. Enter the employee's name, street address, group plan number, and ID number in the designated fields.
3. Include the city or town of your residence along with the name of your employer and ZIP code.
4. If the claim is for a dependent, indicate if the dependent is a child and fill in their information. Confirm if they are a full-time student or if they are married.
5. Specify your occupation and whether your spouse is employed, providing information about their employer if applicable.
6. Sign the form where indicated if you want benefits to be paid directly to the doctor or hospital, and sign for all claims at the designated area.
7. Complete Part B by providing the necessary information, including the date of service and description of service. The physician should sign this part of the form.
8. Once all sections are completed, save changes to the document. You can choose to download, print, or share the completed form as needed.

Complete your forms online now to ensure a smooth submission process.