Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to access the HTH SUNY ICF 001 online and open it in the appropriate editor.
2. Begin filling out the patient information section. Input the family name and given name of the patient. Be sure to provide the insured information, including the certificate number and group name.
3. Complete the birth date and gender fields for the patient. Specify the relationship to the insured member, utilizing options such as self, spouse, son, daughter, etc.
4. Indicate the reimbursement mailing address where the payment should be sent.
5. Respond to the question about other health insurance coverage, providing the name of the insurance company and policy number if applicable.
6. In the medical information section, describe the patient's accident or sickness clearly. If applicable, answer questions regarding whether the medical expense was related to a motor vehicle accident or a work-related illness.
7. Use the medical information section to report any covered health services, ensuring to attach itemized bills for all claims that have not yet been reported.
8. Review the payment method options. Choose between a check payable to you or direct payment to the health care provider.
9. Finally, review all entered information for accuracy, sign the form in the designated area, and include the date of signing.
10. Save the completed form, and then download, print, or share it as necessary for submission along with required documentation.

Complete your documents online now for efficient processing!