Get Statement Of Claim For Members And Dependents

Filing the Statement Of Claim For Members And Dependents online can be a straightforward process if you follow the guidelines outlined in this guide. This document is essential for members and their dependents to claim medical benefits and provides a structured way to submit the necessary information.

Follow the steps to complete the form accurately and efficiently.

1. Press the ‘Get Form’ button to obtain the Statement Of Claim For Members And Dependents form, opening it in your browser or preferred application.
2. Begin by filling in the member's information section, including the member's name, date of birth, ID number, marital status, and membership status. Ensure that each field is completed accurately.
3. Provide the member's mailing address, and check the box if there is a new address. You should also indicate the preferred method of contact, selecting either email or telephone.
4. Next, proceed to the dependent information section. Here, fill in the dependent’s name, relationship to the member, date of birth, gender, and address if different from the member. Confirm their employment status and whether they are a full-time student.
5. In the other coverage information section, indicate if the member or any dependents are covered by other health insurance. If yes, complete the details regarding the policyholder, type of coverage, effective dates, and whether this coverage includes dependents.
6. Provide information about Medicare eligibility if applicable, including the effective dates for Medicare Part A and B. Complete the permission statement affirming the truthfulness of the information provided.
7. Complete the authorization for benefits payment, ensuring you include the provider's details where services were received. The provider must also complete their section or attach itemized bills with all necessary information.
8. Finally, review all entered information for accuracy. Once satisfied, you can save any changes, download a copy of the completed form, print it, or share it as required.

Start filling out your Statement Of Claim For Members And Dependents online today to ensure you receive the benefits you deserve.