Follow the steps to successfully complete your Wellness Health Screening Claim Form.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Begin by completing Section A, which captures the policyholder's information. Provide your policy number, social security number, name, date of birth, phone number, and address. Make sure to indicate your language preference and if you are an employee of Trustmark Companies.
3. Next, fill out Section B, detailing patient information. Include the patient's name, date of birth, social security number, and the relationship to the insured. Attach itemized copies of bills related to the tests performed.
4. In Section B, specify the tests or services received by listing the completion dates next to the relevant services. Ensure to include all applicable wellness services, including any mammograms or preventive screenings.
5. Proceed to Section C, where you must sign and date the form to certify the accuracy of the information provided. This indicates your agreement and understanding of the claims process.
6. If applicable, complete Section D only if the tests were provided through an employer-sponsored wellness clinic and you lack documentation. This section needs to be filled out by the medical professional who conducted the tests.
7. Review all sections for completeness and accuracy. Incomplete or illegible submissions may delay benefit processing.
8. Once all sections are filled out, save your changes, then proceed to download, print, or share the form as needed for submission. Ensure you attach any necessary supporting documents.

Take the first step toward your reimbursement by completing the Wellness Health Screening Claim Form online today.