Afspa Claim Form PDF Details

When filing a claim for an act of violence or sexual assault pursuant to the American Forces Protection Act (Afspa), it is important to understand what information is required by the Department of Defense (DOD) in order to process your claim. This article will provide an overview of the information that must be included in your Afspa Claim Form, as well as additional steps you may need to take in order to receive benefits through this program. Please note that this article is not meant to be exhaustive, and you should always contact a lawyer if you are considering filing a claim under Afspa.

You will see information about the type of form you wish to complete in the table. It can show you how much time it may need to fill out afspa claim form, what fields you will need to fill in and some additional specific facts.

QuestionAnswer
Form NameAfspa Claim Form
Form Length1 pages
Fillable?Yes
Fillable fields74
Avg. time to fill out15 min 7 sec
Other namesafspa form, afspa prior auth form, afspa claim form, afspa lon form

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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afspa lon form fields to complete

Write down the information in IMPORTANT: This question must be, Person in whose name the other, Group or, Family or, Effective Date, Employment Effective Date, Self only coverage, Individual contract, 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:, Hospital (Part A) Effective Date, Medicare (Part B) Effective Date, (c) If you or your spouse are 65, Self: Spouse:, Yes Yes, No Employer No Employer, Authorization for direct payment, and I authorize payment directly to.

part 2 to entering details in afspa lon form

Note the fundamental information since you are on the Authorization for direct payment, for the Medical and/or Surgical, (Signature of member), I certify the information on this, Date, WARNING: Any intentional false, HAVE YOU ANSWERED EVERY QUESTION, HAVE YOU DATED AND SIGNED THIS, and A-POD section.

step 3 to finishing afspa lon form

Step 3: As soon as you select the Done button, your ready document is readily exportable to any of your gadgets. Or, you may deliver it by using mail.

Step 4: You can generate duplicates of the file tokeep clear of all upcoming problems. Don't be concerned, we do not disclose or monitor your information.

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