Get Abj16689-3.doc

Filling out the ABJ16689-3.doc online can streamline your outpatient physician's treatment claim process. This guide offers clear, step-by-step instructions to help you effectively complete the form with confidence.

Follow the steps to complete your form accurately.

1. Click the ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin with the policyholder and certificate holder information section. Fill in the policy number(s) and provide the required personal details such as first name, middle initial, last name, social security number, date of birth, mailing address, age, and gender. Check the box if the address is new.
3. Next, complete the patient's information section. Again, provide the first name, middle initial, last name, social security number, date of birth, and specify the relation to the insured. Mark the appropriate age and gender as needed.
4. In the outpatient physician's treatment benefit section, detail the benefit for treatment provided outside of a hospital. Attach any required documentation, including the provider's name and address, as well as the date(s) of service. Be sure to include a copy of the bill or treatment documentation.
5. If applicable, fill out the assignment of benefits section, providing the name and address of the person who should receive the benefits. Include the provider's tax identification number and relation to the policy owner.
6. Read and sign the certification section, confirming that you have received the necessary information regarding claims and affirming that your answers are true and complete.
7. Complete the authorization section, signing and dating as required. Check the box if your mailing address is new.
8. Finally, review all the information for accuracy. Once confirmed, you can save the changes, download the form, print it, or share it as needed.

Complete your outpatient treatment claim online today!