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Filling out the Hospital Indemnity Claim Form can be a straightforward process when you have a clear guide. This document aims to provide you with step-by-step instructions, ensuring you complete the form accurately and efficiently to facilitate timely processing of your claim.

Follow the steps to complete your claim form correctly.

1. Press the ‘Get Form’ button to access the Hospital Indemnity Claim Form, ensuring you can fill it out appropriately online.
2. Enter your policy number(s) at the top of the form. Ensure these are correct to avoid processing delays.
3. Complete the sections for the Name of Insured, Name of Patient, Address (Street, City, State, Zip Code), Phone, and Email. Providing accurate contact information is crucial for efficient communication.
4. Specify the condition causing the claim and provide the date the patient first became ill or the date of the accident. If applicable, describe how the accident occurred.
5. Include the date the patient first consulted a doctor regarding their condition.
6. Indicate whether you have filed a Workers’ Compensation claim by checking 'Yes' or 'No.' If 'Yes,' provide the employer’s name and address.
7. List the treating doctor’s name, address, and phone number, along with your family doctor’s details and any other medical professionals seen in the last two years.
8. Ensure to sign and date the form in the Insured Member Signature section. It is important to confirm that all provided information is true and complete.
9. Complete the HIPAA authorization section by printing and signing as necessary, ensuring it is included with your claim submission.
10. Gather any additional necessary documents, such as billing statements in the form of UB-04 forms, and ensure they accompany the completed claim form.
11. Finally, send your completed claim form, authorization, and itemized bills to the specified address, fax number, or email provided on the form to submit your claim.

Start completing your Hospital Indemnity Claim Form online for a smooth claims process.