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Medical Claim

Subscriber Information

If you have checked Yes to any of the above, please provide...
If you are covered by Medicare, or any other basic hospitalization or surgical plan such as Blue Cross-Blue Shield, please submit these carrier’s payment statements or declinations along with itemized bills.

Complete For Injury Or Illness

If Claim For Dependent, Complete This Section Also

Important – Please Complete Authorization Section

The above answers are true and correct to the best of my knowledge. I hereby authorized any physician, surgeon, practitioner or other person, any hospital, including veterans administration or government hospital, any medical service organization, any insurance company, or any other institution or organization to release to each other any medical or other information acquired, including benefits paid or payable, concerning this or other disabilities. A Photostat of this authorization shall be as valid as the original.
I hereby assign my rights to benefits (including all rights arising under § 514(a) of ERISA, 29 U.S.C. §1144(a)) to, and authorize payment directly to, the Physician named above for those benefits to which the Plan Member is entitled, provided the benefits paid do not exceed the Physician’s regular charges. I understand I am financially responsible to the Physician for charges not covered by this assignment.
Vision Claim

Subscriber Information

If Claim For Dependent, Complete This Section Also

Complete for Vision Services Or Attach Itemized Bill

   Upload Physician's Signed and Dated Prescription

Complete for Vision Supplies Or Attach Itemized Bill

   Upload Supplier's Signed and Dated Note

Important – Please Complete Authorization Section

The above answers are true and correct to the best of my knowledge. I hereby authorized any physician, surgeon, practitioner or other person, any hospital, including veterans administration or government hospital, any medical service organization, any insurance company, or any other institution or organization to release to each other any medical or other information acquired, including benefits paid or payable, concerning this or other disabilities. A Photostat of this authorization shall be as valid as the original.
I hereby assign my rights to benefits (including all rights arising under § 514(a) of ERISA, 29 U.S.C. §1144(a)) to, and authorize payment directly to, the Physician named above for those benefits to which the Plan Member is entitled, provided the benefits paid do not exceed the Physician’s regular charges. I understand I am financially responsible to the Physician for charges not covered by this assignment.
Other Insurance
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Covered Members Without Other Insurance Coverage

Please list the Name and Date of Birth for all covered members who do NOT have other insurance coverage (including yourself):
I declare under penalty of perjury that the above statements are true and complete to the best of my knowledge.
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Dependent Information

Claim Reason

Payment Information

Proof of payment should be attached, please also attach a copy of the claim in the attachments section below. Valid Proof of Payment
  • Bank statement clearly identifying payment to provider
  • Cancelled check
  • Credit card receipt
  • Cash paid receipt
A payment will be made to the provider of service, please also attach a copy of the claim in the attachments section below.
I declare under penalty of perjury that the above statement are true and complete to the best of my knowledge
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Dependent Information

Provide Information About The Test Kits You Purchased

The undersigned participant certifies that the test kits purchased were NOT for employment purposes. The undersigned participant certifies that the test kits were NOT purchased for resale. The undersigned participant in the Medical Plan certifies that all expenses for which reimbursement is claimed by submission of this form, were purchased while the undersigned was covered under the Employer’s Medical Plan and that such expenses have not been reimbursed, or are not reimbursable, by any other entity, health plan or flexible spending account. The undersigned understands that he or she alone is fully responsible for the sufficiency, accuracy and veracity of all information relating to this claim which is provided by the undersigned, and that unless an expense for which reimbursement is claimed as a proper expense under the Plan, the undersigned may be liable for the payment of all related taxes including federal, state or city income tax on amounts paid by the Plan which relate to such expense.
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