Follow the steps to successfully complete your medical claim form online.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by completing the Member Information section. Provide your last name, first name, middle initial, and Member ID Number.
3. If the claim is for a qualified dependent, fill out the Patient Information section with the dependent’s details, including their last name, first name, middle initial, patient ID, date of birth, relationship, and sex.
4. Next, complete the Accident Information section only if the claim is related to an accident or work-related illness. Include the date of the accident, location, employment relation, a description of the accident or illness, the date of the first consultation, and any previous similar symptoms.
5. If the patient is eligible for Medicare, fill out the Medicare Information section. Be sure to include the Medicare number and effective dates for Part A and Part B. Attach a copy of the 'Explanation of Benefits' from your Medicare insurance carrier.
6. Next, indicate if you have other health insurance. If applicable, provide the name of the policyholder, policy number, street address, insurance company name, and phone number.
7. In the Authorization/Release of Information section, your signature is required to authorize the Plan to obtain necessary information for processing the claim. Include the date of your signature.
8. In the Assignment of Benefits section, sign and date to authorize direct payment to the provider of services.
9. Once all sections are completed, check to ensure that you have attached any fully itemized bills along with necessary supporting documentation. Save your completed form.
10. Finally, you can download, print, or share the form as needed, and submit it according to the instructions provided on the form.

Complete your medical claim form online today and ensure a smooth claims process!