Follow the steps to complete your LTC Claim Form efficiently.

1. Press the ‘Get Form’ button to obtain the LTC Claim Form and open it for editing.
2. In Part A, begin by entering the patient’s last name, first name, and middle initial. You will also need to fill in the policy number associated with the patient.
3. In the authorization section, you must sign and date to authorize payment to the institution named, indicating your understanding of the financial responsibilities.
4. Next, provide your signature and date for the release of any necessary medical information that may be required to process your claim.
5. In Part B, this section is to be completed by the long-term care facility. Enter the primary diagnosis and any additional diagnoses as applicable.
6. Fill out the name and address of the institution and provide the facility's phone number.
7. Enter the admission date to the facility and the federal tax ID number. Select the type of care being claimed by circling the appropriate services used.
8. If applicable, list any hospital confinements along with their respective dates and discharge dates.
9. In Part C, enter the actual dates of service provided, as well as daily or monthly charges. Ensure that you separate each confinement by month and detail any Medicare service payments.
10. Finally, sign and print the name of the person who completed the form. Make sure to attach copies of the necessary documentation such as the state license and doctor’s orders.

Complete and submit your LTC Claim Form online for a faster processing experience.