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Form Lc-7363-1 (Mlic) - Statement Of Claim And Instructions On How To Submit A Tricare/champva Supplement Claim

P.O. Box 2510

Rockville, Maryland 20847-2510

1-800-638-2610

Underwritten by Monumental Life Insurance Company

STATEMENT OF CLAIM

INSTRUCTIONS ON HOW TO SUBMIT A TRICARE/CHAMPVA SUPPLEMENT CLAIM

1. The form must be completed by the Member and;

2. Send the appropriate medical bills, hospital bills and all Explanation of Benefits worksheets from TRICARE/CHAMPVA

to: Claims Department, Group Insurance Administrator, P.O. Box 2510 Rockville, Maryland 20847-2510

3. TRICARE Prime claimants must submit a receipt from the provider of care showing the paid co-payment amount.

Name of Member

Member ID#

Sex

Male

Female

Date of Birth

Social Security Number

Marital Status

Single

Married

Other___________________

Address (Street, City, State & Zip Code)

Name of Association/Organization/Credit Union/Employer

Type of Claim:

Prime

Standard

CHAMPVA

TRICARE

Name of Patient

Relationship to Member

Date of Birth

Spouse

Daughter

Son

Other

Address of Patient (Street, City, State & Zip Code)

Nature of Accident or Illness - Describe

Have you claimed benefits for this condition previously?

Yes If Yes, when? ________________

Assignment of Benefits

I hereby authorize payment of eligible benefits under my policy in connection with this injury or illness to:

Name of Provider of Care (Doctor, Hospital, etc.) ______________________________________________________________

_______________________________________

___________________________________

_______________

Signature of Patient or Guardian

Relationship to Patient if Signed by Guardian

Date

LC-7363-1 (MLIC)

Page 1 of 2

9/2012

Form Lc-7363-1 (Mlic) - Statement Of Claim And Instructions On How To Submit A Tricare/champva Supplement Claim

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