Get Direct To Vendor Payment Health Expense Claim ... - Eastern Shawnee

This guide provides comprehensive instructions on how to complete the Direct To Vendor Payment Health Expense Claim form for Eastern Shawnee. By following the steps outlined below, you will be able to fill out the form accurately and efficiently, ensuring that your health expense claims are processed smoothly.

Follow the steps to complete the form online:

1. Press the ‘Get Form’ button to access and open the Direct To Vendor Payment Health Expense Claim form for Eastern Shawnee in your preferred editing tool.
2. Fill in the tribal member information section, including the tribal member’s name, date of birth, phone number, ID number, and email address. Make sure the information is accurate to avoid delays.
3. Provide your mailing address and indicate if it is a new address or if you have made any changes.
4. In the insurance information section, indicate whether the member is covered under any health insurance plan by selecting 'Yes' or 'No.' If 'Yes,' complete the required fields including the name of the policyholder and the insurance company's name and address.
5. If applicable, provide information regarding Medicaid coverage by indicating 'Yes' or 'No' and filling in the I.D. number and state covered.
6. For Medicare details, if applicable, include the name of the Medicare beneficiary, their Medicare number, and the type of coverage (Part A, Part B, and/or Part D) along with the effective dates for each.
7. Complete the grid for the direct to vendor request. For each medical expense, fill out the name of the service provider, a description of the medical service, date of service, and amount of claim. Remember to attach any supporting documentation required.
8. Sign the form, certifying that the information provided is accurate and that the expenses were incurred by the named patient. Indicate the date of signing.
9. Save changes, and then you can download, print, or share the completed form as needed.

Take the time to accurately complete your forms online for a smooth claims process.