Form 110602 - Customer Claim Form printable pdf download

Form 110602 - Customer Claim Form

FOR OFFICE USE ONLY

Please

Do Not

Staple

CUSTOMER

On Bars

CLAIM

FORM

P.O. Box 27401, Richmond, VA 23279

Please see the other side of this form for instructions and mailing information. A separate Customer Claim Form is

required for each patient; attach only the bills for that family member. Please print or type all information.

INSURED AND PATIENT INFORMATION –

ALL SECTIONS MUST BE COMPLETED

Insured’s Name (as shown on ID card)

Identification Number (as shown on ID card)

First

M.I.

Last

(Letters if any)

(

)

Patient’s Name

Patient’s Date of Birth

Patient’s Sex

First

M.I.

Last

Month

Day

Year

Male

Female

Patient’s Relationship to Insured

Self

Spouse

Dependent Child

Insured’s Street Address (

check if new address)

City

State

Zip Code

Daytime Phone Number

(in case additional information is needed)

(

)

PATIENT’S CONDITION AND TREATMENT

Treatment was for

Condition was due to

If injury, give date

Month

Day

Year

Illness

Injury

Work-Related Injury/Illness

Auto Accident

Other

What illness or injury was the patient treated for?

First date care was received for this illness or injury

Month

Day

Year

ATTACHMENTS

Please check the types of documents you have attached copies of:

Itemized bill(s) for this patient

Statement(s) showing how the same services were paid by the patient’s primary health insurance company

Statement(s) showing Medicare’s payment for the same services

AUTHORIZATION

I certify that the information on this form is complete and correct to the best of my knowledge. I authorize the release of any

medical information necessary to process this claim.

Signature of Insured _____________________________________________________

Date ___________________________________

SEE INSTRUCTIONS ON OTHER SIDE BEFORE MAILING

110602 (R 12/02)

Form 110602 - Customer Claim Form

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