PLACE STAMP HERE PreferredOne Administrative Services P. O. Box 59212 Minneapolis MN 55459-0212 EMPLOYER GROUP NUMBER EMPLOYEE S NAME Last First Middle Initial SOCIAL SECURITY NUMBER EMPLOYEE S ADDRESS CITY STATE ZIP CODE TELEPHONE NUMBER PATIENT S NAME DATE OF BIRTH SELF SPOUSE CHILD ARE YOU YOUR SPOUSE AND/OR DEPENDENTS COVERED UNDER ANY OTHER HEALTHCARE POLICY AT THE TIME THE ENCLOSED CLAIM WAS INCURRED YES NO IF YES LIST NAME OF CARRIER AND MEMBERS COVERED WHAT IS THE NAME AND ADDRESS OF THE COMPANY AND THE POLICY NUMBER NATURE OF ILLNESS OR INJURY IF ACCIDENT STATE WHEN WHERE AND HOW IT OCCURRED If the claim is on a dependent who is over 19 years old and a full-time student identify name and address of school PATIENT S OR AUTHORIZED PERSON S SIGNATURE I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. INSURED S OR AUTHORIZED PERSON ....
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How to fill out the Preferred One Claim Form online
Filling out the Preferred One Claim Form can seem overwhelming, but it is a straightforward process when approached step-by-step. This guide will assist you in completing the form online efficiently and accurately.
Follow the steps to complete the Preferred One Claim Form online.
- Press the ‘Get Form’ button to access the form and open it in your preferred document editor.
- Begin by entering your employer's name and group number in the relevant fields. This information is crucial for identifying your insurance plan.
- Next, provide your name in the designated fields: last name, first name, and middle initial. Accuracy here is essential as it corresponds to your insurance documentation.
- Fill in your social security number where indicated. Make sure to double-check for accuracy to avoid delays in processing your claim.
- Input your complete address, including city, state, and ZIP code. This ensures that any correspondence related to your claim reaches you without issue.
- Provide your telephone number, which may be used for any necessary follow-up regarding your claim.
- Next, enter the patient's name, check the appropriate box for their relationship to you (self, spouse, or child), and include their date of birth.
- Indicate whether you, your spouse, or dependents are covered under any other healthcare policy at the time the claim occurred by checking the yes or no option. If yes, list the name of the carrier and members covered.
- Detail the nature of the illness or injury, including specifics if it was an accident—such as when and where it happened.
- If applicable, provide the name and address of the school for dependents over 19 years old who are full-time students.
- Both the patient or authorized person's signature and the insured's or authorized person's signature are required. Sign and date accordingly, authorizing the release of necessary information for claim processing.
- Lastly, ensure to send the original bills related to the claim, not photocopies. If any bills have already been paid, mark them as 'paid.' Review all information before saving your completed form.
Start filling out your Preferred One Claim Form online today to ensure timely processing of your claim.
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