Get Centerlight Claim Form

Filling out the Centerlight Claim Form online can seem daunting, but this guide provides clear, step-by-step instructions to help you complete the process smoothly and accurately. We aim to support users of all backgrounds in submitting this important document.

Follow the steps to successfully complete the Centerlight Claim Form online.

1. Click ‘Get Form’ button to obtain the Centerlight Claim Form and open it in your preferred online editor.
2. Begin by entering your basic information. Fill in your last name, first name, middle initial, and home phone number. Ensure your birth date is formatted correctly (MM/DD/YYYY).
3. Provide your permanent residence street address, including city, state, and zip code. Note that P.O. Box addresses are not accepted.
4. If your mailing address differs from your permanent residence, fill in the relevant fields. Otherwise, you may skip this step.
5. Fill out emergency contact information. Provide the name, relationship, and phone number of a person we can reach in case of emergencies.
6. Complete the Medicare Insurance Information section by entering your Medicare Claim Number exactly as it appears on your card. Make sure to note whether you have Medicare Part A and Part B, and attach a copy of your Medicare card if required.
7. Select your preferred premium payment option from the choices provided. Indicate whether you prefer to receive a monthly bill or use automatic deduction from your Social Security benefits.
8. Answer the important health questions regarding End Stage Renal Disease, other drug coverage, long-term care facility residency, and Medicaid enrollment. Provide required details if applicable.
9. Choose your primary care physician and dentist from the provided options, indicating whether you are currently a patient of either.
10. Lastly, read the important information section carefully, sign the form, and date it. If you are an authorized representative or witness, make sure to provide the additional required information.
11. Once you have completed the form, save your changes. You can then download, print, or share the form as needed.

Start filling out your Centerlight Claim Form online today to ensure a smooth enrollment process.