Follow the steps to fill out the claim form correctly.

1. Press the ‘Get Form’ button to access the form and open it in your document management tool.
2. Complete the Employee/Retiree Data section. Make sure to include the employee's full name, home address, work phone number, and HealthPlan Services Member ID, which starts with 'Q9' as shown on the plan identification card.
3. Fill out the Patient Data section. This includes the patient's name, date of birth, age, sex, and relationship to the employee. Additionally, indicate whether the patient is a disabled dependent and if the charges were incurred due to an on-the-job illness or injury.
4. Complete the Other Insurance Data section by indicating if the patient has other health insurance. Provide the name and address of the insurance company if applicable.
5. In the Physician or Supplier Information section, include the billing name, address, phone number, Tax ID number of the provider, description of the diagnosis, and all supporting documentation. Ensure to enter the date(s) of service, procedures, services, CPT codes, and signature of the physician/supplier.
6. Review the Authorizations section. Sign and date to authorize the payment and the release of medical records relevant to the claim.
7. After ensuring that all required fields are filled out correctly, save the changes made to the form. You can then download, print, or share the completed claim form along with all supporting documentation.

Start filling out your HealthPlan Services claim online today to ensure your healthcare expenses are reimbursed.