Get Member Submitted Health Insurance Claim Form ... - Cheyney

Filling out the MEMBER SUBMITTED HEALTH INSURANCE CLAIM FORM is an essential process for ensuring that your health care expenses are reimbursed efficiently. This guide provides step-by-step instructions to navigate the form accurately and effectively.

Follow the steps to complete your health insurance claim form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the patient information section. Include the patient's name, address, date of birth, and sex. This information is critical for identifying the individual seeking reimbursement.
3. Complete the ID card information. Fill in the name and identification number as they appear on the ID card, along with the group number. This data ensures that the claim is processed under the correct policy.
4. Indicate the patient's relationship to the person named on the ID card. Specify whether the patient is self, spouse, child, or other, as this impacts coverage details.
5. If the patient is covered by another insurance plan, fill in the other insurance coverage information. This includes the insured's name, insurance company's name, and policy number, ensuring all possible coverage is accounted for.
6. If the claim is related to an accident, select the appropriate checkbox for the type of accident and provide the date of the incident. This information is necessary for determining liability and eligibility for services.
7. Determine if the patient is a full-time student over 19 years old and provide the school's name, address, and dates of the current term. This is relevant for any educational benefits that might apply.
8. Carefully read the certification section. By signing, you confirm that all information is accurate and authorize insurers to release information as necessary. Provide your signature and date in the specified fields.
9. Finally, ensure you attach an itemized statement of services from the healthcare provider. This should include detailed information about the treatment provided, such as patient name, dates of service, type of services performed, diagnosis, and charges.
10. Once completed, review the entire form for accuracy. You can then save changes, download, print, or share the form as needed for submission.

Complete your health insurance claim form online today to ensure timely processing of your claims.