Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by selecting your status as either retired or a survivor by checking the appropriate box.
3. Fill in your identification details, including the employee’s name, date of birth, local number, and registration number.
4. If the claim is for a spouse, insert the spouse's name in the designated field.
5. Understand that you need to submit any Medicare notices with the claim. This includes the Record of Hospital Benefits or Explanation of Benefits.
6. In Part 3, specify if the patient has coverage from any other insurance or health services plan by checking 'Yes' or 'No'. If 'Yes', provide the policy number, name, and address of the other plan.
7. Proceed to address whether the patient’s condition is due to an accident, injury, or illness related to employment. Check 'Yes' or 'No'.
8. If applicable, indicate if a claim has been filed under any Federal or State Workers’ Compensation Law and respond accordingly.
9. Continue detailing whether the patient’s condition results from an accident caused by another party. Again, respond with 'Yes' or 'No'.
10. If 'Yes' to the previous question, state whether a legal action has been initiated against the other party.
11. Review the answers to ensure accuracy. Sign the authorization in Part 10, and ensure the date is filled out.
12. If you wish to have benefits assigned directly to a hospital or doctor, complete the optional assignment section, including the dates and signatures.
13. Lastly, ensure all required Medicare notices are attached, then save your completed form. You may download, print, or share as needed.

Start completing your claims form online today for a smoother benefits process.