Afspa Claim Form PDF Details

Navigating through the healthcare claim process can be a complex endeavor, especially when dealing with plans that cater to specific groups such as the Foreign Service Benefit Plan, highlighted in the AFSPA Claim Form. This form is a crucial document for insured members who need to submit claims for healthcare services received. It meticulously asks for detailed information starting from the member's personal details, such as full name, sex, date of birth, and mailing address, to more specific data related to the healthcare service or incident, like the nature of the sickness or accident and the physician's particulars. Additionally, it inquires whether the claim involves other insurance or Medicare coverage, an essential step for coordination of benefits. The form also includes critical sections on dependent information if the claim includes expenses for a family member, and subtly reminds members over the age of 65 or those receiving disability benefits to detail their Medicare coverage. Completion and accuracy of this form are paramount, underscored by the warning at the document's end regarding the legal consequences of false statements. This emphasizes the form's role not only as a procedural necessity but also as a legal document. Furthermore, the form facilitates direct payment to healthcare providers if authorized by the member, streamlining the reimbursement process. Each section of the AFSPA Claim Form is designed with the insured member's convenience and the need for precise information in mind, ensuring that claims are processed efficiently and accurately for those under the FOREIGN SERVICE BENEFIT PLAN.

QuestionAnswer
Form NameAfspa Claim Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesafspa form, afspa policy, afspa claim form, claim form group

Form Preview Example

CLAIM FORM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHECK HERE

GROUP POLICY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IF NEW

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

285630

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SINCE LAST

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUBMISSION.

FORWARD COMPLETED CLAIM FORM TO: FOREIGN SERVICE BENEFIT PLAN

 

 

 

DATE

 

 

 

 

 

RELOCATED

 

 

 

 

 

 

 

1620 L STREET, NW, SUITE 800

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

PHONE: (202) 833-4910

 

 

 

WASHINGTON, DC 20036-5629

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLEASE PRINT

 

 

 

TO BE COMPLETED BY INSURED MEMBER

 

 

 

 

PLEASE PRINT

All items must be answered in full before your claim can be processed.

 

 

 

 

 

 

 

 

 

 

 

 

 

Member’s full name

 

 

 

 

 

 

 

 

Sex

 

 

Date of Birth

 

 

 

 

 

 

 

 

 

Member’s mailing address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Number and Street)

 

 

 

(City)

 

(State)

 

(Zip Code)

Member’s Subscriber ID

 

 

 

 

 

Enrollment Code Self Only 401

Self Plus One 403

Self & Family 402

If claim is for a dependent, given name

 

 

 

 

Relationship

 

 

Date of Birth

 

 

 

 

 

 

 

 

 

Dependent’s marital status (check one)

single

married

 

 

 

 

 

 

 

 

 

 

 

Name of dependent’s employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Describe Sickness/Accident Suffered

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If Accident: (a) Date of accident

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Month)

 

 

 

(Day)

(Year)

 

(Hour)

 

 

 

 

(b)How and where did accident occur? Was accident or sickness work related? Yes No Physician’s Name

If “Yes” please contact your workers’ compensation office for guidance. Address

OTHER INSURANCE/MEDICARE COVERAGE INFORMATION

(See section on coordination of benefits in your Brochure)

IMPORTANT: This question must be answered and the form signed before claim can be processed.

(a) Are you or any member of your family covered under any health plan other than FOREIGN SERVICE BENEFIT PLAN? YES NO

(b)If answer is “Yes”, complete the following: Person in whose name the other plan is issued Name of all dependents covered under the other plan

Name of Insurance Company or Plan

 

 

 

Effective Date

Address of Claims Office

 

 

 

 

 

 

 

 

 

 

 

Is this insurance through active employment?

 

 

 

Employment Effective Date

 

Policy or Contract Number

 

 

 

Is Plan

Family or

Self only coverage? (Check appropriate block)

(c) Is this other plan issued under a

Group or

Individual contract? (Check appropriate block)

IMPORTANT:This question must be fully answered by persons age 65 or older and persons under age 65 receiving disability

 

 

benefits through Social Security.

 

 

 

 

 

 

Medicare coverage (see your official Brochure)

 

 

 

 

 

 

(a)

Are you or any member of your family covered under Medicare?

Yes

No

(b)

If “Yes”, indicate name of person and check the type of coverage.

 

 

 

 

SELF:

 

 

 

 

 

Hospital (Part A)

Effective Date

 

 

 

Medicare (Part B) Effective Date

 

SPOUSE:

 

 

 

 

Hospital (Part A)

Effective Date

 

 

 

Medicare (Part B) Effective Date

 

DEPENDENT:

 

 

 

Hospital (Part A)

Effective Date

 

 

 

Medicare (Part B) Effective Date

 

(c)

If you or your spouse are 65 or over, indicate whether you are actively employed.

Self:

 

Yes

No

Employer

 

 

 

 

 

 

 

Spouse:

Yes

No

Employer

 

 

 

 

 

 

 

Authorization for direct payment of benefits.

I authorize payment directly to

(Print name of physician)

for the Medical and/or Surgical Benefits otherwise payable to me.

Date, 20 Signed

(Signature of member)

I certify the information on this form is complete and accurate.

Signature of patient or member

Date

WARNING: Any intentional false statement in this application or willful misrepresentation relative thereto is a violation of the law punishable by a fine of not more than $10,000, or imprisonment of not more than five years, or both. (18 U.S.C. 1001)

HAVE YOU ANSWERED EVERY QUESTION?

 

HAVE YOU DATED AND SIGNED THIS FORM?

 

 

GC-16435 (12-17)

1

A-POD

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part 1 to writing afspa insurance claim form

The program will need you to submit the IMPORTANT This question must be, Yes, Person in whose name the other, Group or, Family or, Effective Date, Employment Effective Date Self, Individual contract Check, IMPORTANT This question must be, benefits through Social Security, Medicare coverage see your, a Are you or any member of your, Yes, SELF SPOUSE DEPENDENT, and Hospital Part A Effective Date box.

afspa insurance claim form IMPORTANT This question must be, Yes, Person in whose name the other, Group or, Family or, Effective Date, Employment Effective Date Self, Individual contract Check, IMPORTANT This question must be, benefits through Social Security, Medicare coverage see your, a Are you or any member of your, Yes, SELF SPOUSE DEPENDENT, and Hospital Part A Effective Date blanks to fill out

You'll be asked to enter the details to help the system prepare the field I certify the information on this, Date, WARNING Any intentional false, HAVE YOU ANSWERED EVERY QUESTION, HAVE YOU DATED AND SIGNED THIS FORM, and APOD.

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