Get Member Submitted Claim Form - Lifewise Health Plan Of Washington

Filling out the Member Submitted Claim Form for LifeWise Health Plan of Washington is an important step in managing your health benefits. This guide provides a clear and supportive overview of each component of the form, ensuring that users can complete it accurately and efficiently online.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to obtain the document and open it in your preferred editing tool.
2. Begin by filling in the member’s information. Enter the first name, last name, and date of birth in the specified fields.
3. Provide the member’s ID number, as well as the first name, last name, and relationship to the member of the person you are authorizing in Section 2.
4. Fill in the city, state, and zip code of the authorized individual, and provide their contact information, including fax and phone number.
5. Indicate your reason for authorizing this individual by checking the appropriate box or writing an explanation under 'Other.' Ensure at least one option is selected.
6. In Section 4, specify what types of health information can be shared. Check at least one box from the options provided.
7. Confirm whether the authorized individual can access your online accounts by checking 'yes' if you wish to allow full access.
8. Review the information you have provided. Ensure accuracy. After reviewing, you will need to print the form to provide your signature.
9. Sign and date the form, and if applicable, include your printed name. If someone other than the member is signing, specify their relationship in the designated area.
10. Once completed, you can save changes, download, print, or share the filled-out form as necessary.

Complete your Member Submitted Claim Form online today to manage your health benefits effectively.