Get Indiana University Health Center Claim Form

Filling out the Indiana University Health Center Claim Form can be a straightforward process when approached step by step. This guide will provide you with clear instructions tailored to help you successfully complete the form online.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Select the appropriate insurance plan by checking one of the options provided (SAA, International, Grad/Undergrad, or School of Medicine).
3. Fill in the patient's name if they are not the student; otherwise, enter the student's name as it appears on their ID card.
4. Enter the student ID number, address, patient date of birth, city, state, and zip code.
5. Provide a telephone number to enable further communication if necessary.
6. To expedite processing, ensure to include the Walk-out statement from the IU Health Center and any detailed pharmacy receipts if applicable.
7. Check the boxes regarding whether your name and ID number are marked clearly on all pages and if the claim stems from an auto, work, or intercollegiate sports accident.
8. Sign and date the authorization for medical information, ensuring that if you are under 18, a parent or guardian has signed.
9. Compile the completed claim form, Walk-out statement, and any pharmacy receipts into an envelope.
10. Address the envelope to Chickering Claims Administrators, Inc., and include your return address, place a stamp, and send it through the mail.

Start filling out your claim form online today for a seamless submission experience.