Afs Medical Claim Form PDF Details

If you are an American expat who has been seriously injured while living or working in a foreign country, you may be eligible to file an AFS medical claim form. This document can help you receive compensation for your medical expenses and other related costs. However, before filing a claim, it is important to understand the process and what information is required. In this article, we will provide an overview of the AFS medical claim form and how to submit it. We will also discuss the eligibility requirements and what benefits you may be able to receive.

Question	Answer
Form Name	Afs Medical Claim Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	SNF, NH, LMP, customerservicegmmusa

Form Preview Example

SUBMIT CLAIM FORM TO:

Global Medical Management, Inc. (GMMI)

1300 Concord Terrace, Suite 300

Sunrise, FL 33323

Phone: (888) 444-7773

Fax: (954) 370-8130

e-mail: customerservice@gmmusa.com

AFS-USA, INC.

MEDICAL CLAIM FORM

PLEASE READ THIS IMPORTANT INFORMATION

•Healthcare providers submitting claims directly to GMMI do not have to complete this form.

•Host family or participant should complete this form if requesting reimbursement for bills already paid by them. If you are given a copy of the industry standard HCFA-1500 or UB-92 Form by the healthcare provider, attach it to this form. If you do so, there is no need to complete the “physician or supplier” section on the back page of this form.

•Reimbursement requests for prescription medications must be accompanied by the original prescription receipt. The prescription receipt is the tag/label that comes attached to the medication containing the student name, doctor/medicine/pharmacy name, date filled, cost, etc.

PARTICIPANT STATEMENT

_______________________________________________________________________________

PARTICIPANT NAME (FIRST)

____________________________________________________________________

(LAST)

____________________________________________________________________

PARTICIPANT ID#DATE OF BIRTH (MM/DD/YYYY)

____________________________________________________________________

PARTICIPANT’S COUNTRY OF ORIGIN

PROGRAM START DATE (MONTH/YR.)

___________________________________________________________________________

HOST FAMILY’S NAME

_________________________________________________________________

STREET ADDRESS

_________________________________________________________________

CITYSTATE ZIP

_________________________________________________________________

HOST FAMILY’S PHONE NO. (WITH AREA CODE)

SERIOUS illness, injury or accident MUST be reported to your AFS Regional Service Center immediately by telephone (800-876-2377) with date when accident/illness occurred, name, address and telephone numbers of attending physician and hospital/clinic. Serious cases are motor vehicle accidents, hospitalizations, broken bones, etc. Please consult your HANDBOOK then complete this form and mail to GMMI.

MINOR illness or injury should be described fully on this form and mailed to GMMI on the same day illness or injury occurred.

Is this illness related to any condition existing prior to arrival in the US?

PHYSICIAN

___________________________________________________________

NAME

____________________________________________________________________

ADDRESS

____________________________________________________________________

CITYSTATEZIP

____________________________________________________________________

(AREA CODE) TELEPHONE NUMBER

Yes

HOSPITAL/CLINIC

_________________________________________________________

NAME

_________________________________________________________________

ADDRESS

_________________________________________________________________

CITYSTATEZIP

_________________________________________________________________

(AREA CODE) TELEPHONE NUMBER

_______________________________________________	_____________________________________________	_________________________________________
DATE OF ILLNESS	THIS DATE	PROVIDER’S TAX ID#

___________________________________________________________________________________________________________________________________________________________________________

ATTENDING PHYSICIAN (IF DIFFERENT FROM ABOVE)(AREA CODE) TELEPHONE NUMBER

___________________________________________________________________________________________________________________________________________________________________________

ADDRESS

CITY

STATE

ZIP

PAYMENT OF MEDICAL BILL

Is the participant covered by a school or other insurance?

Yes	No (If yes, give name and address)

___________________________________________________________________________________________________________________________________________________________________________

INSURANCE NAME(AREA CODE) TELEPHONE NUMBER

___________________________________________________________________________________________________________________________________________________________________________

ADDRESS		CITY	STATE	ZIP
PLEASE CHECK:	No bill expected	Bill (s) will be forwarded	Bill(s) enclosed and should be paid directly

Paid bills with cancelled check(s) and/or receipt enclosed

PERSON TO BE REIMBURSED - All reimbursement checks payable to participants are issued in US currency and made out to the participant’s name c/o U.S. host family address.

___________________________________________________________

PARTICIPANT NAME

____________________________________________________________________

ADDRESS

____________________________________________________________________

CITYSTATEZIP

____________________________________________________________________

(AREA CODE) TELEPHONE

I certify that the preceding statements and answers, and the attached bills and/or statements are true and complete to the best of my knowledge. I authorize the release of information and medical records to Global Medical Management Inc. containing the diagnosis and treatment provided to me. I understand that this information will be held confidential.

___________________________________________________

Signature	Date (mm/dd/yyyy)
	(OVER)
Jan15/09

ACCIDENT (complete only if claim is due to accident)

In the event of a car accident provide a police report.

DATE OF ACCIDENT

TIME OF ACCIDENT

HOW DID THE ACCIDENT HAPPEN?

WHERE DID THE ACCIDENT HAPPEN?

NAME OF INSURANCE OF OTHER PARTIES INVOLVED
ADDRESS OF INSURANCE OF OTHER PARTIES INVOLVED	CITY	STATE	ZIP

TO HOSPITALS: Attach to this form your bill and a completed copy of your own

PHYSICIANS AND SUPPLIERS: If your form provides the information requested below,

AMA approved form or UB-92 form.

attach a completed copy.

PHYSICIAN OR SUPPLIER INFORMATION

Date of ILLNESS (first symptom), or INJURY (Accident) or PREGNANCY (LMP)

Date patient first consulted you for this condition

Has patient ever

had same or similar symptoms

Yes

Please check:

If other than attending, please give name of referring physician.

Attending Physician

Surgeon

Consulting

Hospital

Name and address of facility where services rendered (if other than home/office)

For services related to hospitalization, give hospitalization dates.

ADMITTED

DISCHARGED

DIAGNOSES May use ICD9-CM or DSM III codes.

PRIMARY

SECONDARY

Date of

Place of Service

Procedure Codes

Full describe procedures: types of therapy, or services furnished for each date given,

Charges

Amount Paid

Balance Due

Service

(Identify)

indicate whether primary or secondary (if mental therapy indicate length of session).

SIGNATURE OF PROVIDER

DATE

DEGREE

Total Charge

Amount Paid

Balance Due

YOUR PATIENT’S ACCOUNT NUMBER

PROVIDER I.D. NUMBER

PROVIDER’S NAME

ADDRESS

CITY

STATE

ZIP

If the services were rendered b a psychiatric worker, the following certification must be completed by the attending physician:

Therapy performed by ______________________________________________________________________________

was conducted at my direction under my supervision and I have consulted with the Therapist

regarding the patient within the last 90 days. Further, I have reviewed and approved the Plan of Treatment and have examined the patient on the date indicated below:

NAME OF ATTENDING PHYSICIAN

DATE OF EXAMINATION

ADDRESS OF ATTENDING PHYSICIAN

CITY

STATE

ZIP

ATTENDING PHYSICIAN’S SIGNATURE

PROFESSIONAL STATUS

Place of service codes:

1 – (H)

Inpatient Hospital

4- (H)

Patient’s Home

7 – (NH)

Nursing Home

O – (OL)

Other Location

2 – (OH)

Outpatient Hospital

5 -

Day Care Facility (Psy)

8 – (SNF)

Skill Nursing Facility

A – (IL)

Independent Laboratory

3 – (O)

Doctor’s Office

6 -

Night Care Facility (Psy)

9 -

Ambulance

B -

Other Medical Surgical Facility

JAN15/09

How to Edit Afs Medical Claim Form Online for Free

Once you open the online tool for PDF editing by FormsPal, it is easy to fill in or edit customerservicegmmusa right here. In order to make our editor better and easier to utilize, we continuously design new features, bearing in mind feedback coming from our users. With a few easy steps, you'll be able to begin your PDF editing:

Step 1: Press the orange "Get Form" button above. It'll open up our editor so you can start completing your form.

Step 2: After you open the file editor, you will find the form prepared to be filled out. Aside from filling out various blanks, it's also possible to perform many other actions with the Document, such as adding your own words, editing the initial text, adding graphics, affixing your signature to the document, and much more.

As for the blank fields of this particular form, this is what you should know:

1. Start completing the customerservicegmmusa with a group of major blanks. Note all of the necessary information and be sure absolutely nothing is neglected!

2. Your next step would be to fill out the next few blank fields: PHYSICIAN NAME ADDRESS CITY , SERIOUS illness injury or accident, HOSPITALCLINIC NAME ADDRESS , No bill expected Paid bills with, THIS DATE, PROVIDERS TAX ID, Bills enclosed and should be paid, If yes give name and address, Bill s will be forwarded, AREA CODE TELEPHONE NUMBER, AREA CODE TELEPHONE NUMBER, Yes, STATE, STATE, and CITY.

As for If yes give name and address and HOSPITALCLINIC NAME ADDRESS , be certain that you take a second look in this current part. The two of these are thought to be the most important fields in the PDF.

3. In this step, examine DATE OF ACCIDENT, TIME OF ACCIDENT, ACCIDENT complete only if claim is, HOW DID THE ACCIDENT HAPPEN, WHERE DID THE ACCIDENT HAPPEN, NAME OF INSURANCE OF OTHER PARTIES, ADDRESS OF INSURANCE OF OTHER, TO HOSPITALS Attach to this form, PHYSICIANS AND SUPPLIERS If your, PHYSICIAN OR SUPPLIER INFORMATION, Date of ILLNESS first symptom or, Date patient first consulted you, Has patient ever had same or, Yes, and Please check If other than. Every one of these will have to be filled in with greatest focus on detail.

4. The following section needs your information in the following places: DIAGNOSES May use ICDCM or DSM III, PRIMARY SECONDARY, Date of Service, Place of Service, Procedure Codes Identify, Full describe procedures types of, Charges, Amount Paid, Balance Due, SIGNATURE OF PROVIDER DATE DEGREE, Total Charge, Amount Paid, Balance Due, YOUR PATIENTS ACCOUNT NUMBER, and ADDRESS CITY STATE ZIP. Ensure that you type in all required info to go further.

Place of Service, Amount Paid, and Total Charge inside Psy

5. This last section to conclude this PDF form is crucial. Ensure to fill in the necessary blank fields, and this includes ADDRESS OF ATTENDING PHYSICIAN, ATTENDING PHYSICIANS SIGNATURE, Place of service codes, H, Inpatient Hospital, OH, Outpatient Hospital, O, Doctors Office, Patients Home, Day Care Facility Psy, Night Care Facility Psy, NH, Nursing Home, and SNF, prior to finalizing. Otherwise, it might contribute to a flawed and probably incorrect document!

Step 3: Just after proofreading the form fields you've filled out, hit "Done" and you're done and dusted! Sign up with us right now and easily obtain customerservicegmmusa, available for downloading. Every last edit made is conveniently preserved , helping you to customize the file later on as needed. FormsPal ensures your data confidentiality with a protected system that never records or shares any kind of private information used. Rest assured knowing your documents are kept protected whenever you work with our service!

Afs Medical Claim Form – Fill Out and Use This PDF

Afs Medical Claim Form PDF Details

Form Preview Example

How to Edit Afs Medical Claim Form Online for Free

Afs Medical Claim Form isn’t the one you’re looking for?

Afs Medical Claim Form – Fill Out and Use This PDF

Afs Medical Claim Form PDF Details

Form Preview Example

How to Edit Afs Medical Claim Form Online for Free

Afs Medical Claim Form isn’t the one you’re looking for?

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