Get Out-of-network Claim Form - Swschp

Filling out the Out-of-Network Claim Form - Swschp online can streamline the process of submitting a claim for services received from out-of-network providers. This guide will help you navigate each section of the form step-by-step, ensuring your claim is processed efficiently.

Follow the steps to complete the Out-of-Network Claim Form online

1. Press the ‘Get Form’ button to access the Out-of-Network Claim Form - Swschp and open it in an online document editor.
2. In Part A, provide your member identification number, full name, date of birth, and gender. Ensure all details are accurate to avoid delays.
3. Proceed to Part B, where you will input the patient information. Include the patient identification number and name. Indicate the relationship to the member, choosing from the provided options.
4. Enter the patient’s date of birth, home phone number, and complete address, including apartment number, city, state, and ZIP code.
5. Answer questions regarding accident involvement by indicating 'yes' or 'no' for claim due to an accident or employment injury. If applicable, describe the incident's details.
6. If the patient has other health insurance, indicate 'yes' and provide the necessary details: name, address, policy number, and effective date.
7. Check the box to confirm if this is a new address, if applicable.
8. Authorize the release of necessary medical information by signing as the patient or authorized representative, and date the signature.
9. Certify the accuracy of the information by having the member or authorized representative sign and date the form.
10. Finally, authorize payment to the physician or provider of services by signing and dating this section.
11. Once completed, you can save your changes, download a copy, print the form, or share it as needed.

Start filling out your Out-of-Network Claim Form online to ensure a smooth claims process.