Get Cl 6003-1018 International Claim Form - Wea.docx

Filling out the CL 6003-1018 International Claim Form online can streamline the process of submitting your claims for services received outside the United States. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete the International Claim Form.

1. Press the ‘Get Form’ button to obtain the international claim form and open it in your preferred editor.
2. Begin with Section 1, labeled ‘Patient Information.’ Fill out the required fields, including the member number, patient's name (first, middle initial, last), phone number, date of birth, sex, subscriber’s date of birth, and subscriber's name. Ensure accuracy in this section to prevent processing delays.
3. Continuing in Section 1, specify the relationship of the patient to the subscriber. Then, enter the subscriber’s current mailing address and patient’s email address.
4. In Section 2 titled ‘Other Health Insurance,’ indicate whether the patient has coverage under any other health insurance, including Medicare. If the answer is ‘Yes,’ proceed to complete the sub-sections 2A through 2E with the relevant insurance details.
5. For Section 3, titled ‘Diagnosis,’ provide information regarding the illness, injury, or symptoms requiring treatment, including the onset date. Indicate if the treatment was due to a work-related accident and provide further details as necessary.
6. In Section 4, titled ‘Charges,’ list each type of service or provider using a separate line. Be sure to attach all itemized bills received, and complete the fields for provider name and address, type of provider, description of services, date of services, and charges.
7. Finally, in Section 5, the form requires a signature. The subscriber, spouse, or patient should sign and date the form, certifying that the information provided is accurate.
8. Once all sections are completed, review the document for accuracy. Save your changes, then download, print, or share the completed form as needed.

Take control of your claims by completing your forms online for a more efficient process.