Get Complimed Gap Claim Form - Prosperityhealth.com

This guide provides clear and supportive instructions for users on how to accurately complete the COMPLIMED GAP CLAIM FORM online. By following these steps, you can ensure that your claim is processed efficiently.

Follow the steps to successfully complete your claim form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section A, provide your principal insured details. This includes your member number, date of birth, first name, surname, telephone number, cellphone number, email address, and product joining date.
3. Still in Section A, fill in the relationship to the member, diagnosis, and postal address.
4. Move to Section B and enter the patient details as required.
5. Proceed to Section C 1. Fill in the submission details for Hospicash, including the name of the hospital, admission date and time, authorization number, discharge date and time, as indicated.
6. In Section C 2, fill in the submission for GAP COVER. Include the healthcare provider number, name, account amount, and treatment dates. Attach copies of all related claims and PSEMAS statements as proof of payment and GAP rejection.
7. Next, in Section C 3, provide the names of the deceased member and the beneficiary for funeral claims. Attach the necessary copies of identification and the death certificate.
8. Section D requires you to input bank details for EFT claim refunds. Include the account holder's name, bank name, type of account (cheque, transmission, savings), branch code, and account number. Remember to attach proof of bank account details.
9. Finally, review Section E for the declaration. Sign and date the form accordingly.
10. Once all sections are completed, you can save changes, download, print, or share the form as needed.

Complete your documents online now to ensure a seamless claim process.