ASPCA Pet Health Insurance Claim Form at a glance
What it is: Claim Form of ASPCA Pet Health Insurance.
Who signs: Form U0314 - CS22: fill out this form completely and sign it. You don't need your veterinarian's signature.
Where and when to file: Fax, mail or email your form with invoice(s) within 270 days of treatment.
Where to get it: Need more claim forms? Download forms at: my.aspcapetinsurance.com
What to bring and attach to ASPCA Pet Health Insurance Claim Form
3 Easy Ways to Submit a Claim Form: you must submit an itemized invoice with this claim form.
Include a copy of your pet's medical records to help expedite processing.
List your account number on all documents you send to ASPCA Pet Health Insurance.
A filled-in ASPCA Pet Health Insurance Claim Form example: a dog owner files an illness claim
How to fill out ASPCA Pet Health Insurance Claim Form, box by box
Your Information and Pet Information
Under Your Information, enter your Name, Address, City, State, Zip, Phone and Email, and check the box if this is a new address.
Under Pet Information, enter the Account Number, Name, Breed, Age and Gender.
Story of Occurrence/Diagnosis
Describe this incident in the Story of Occurrence/Diagnosis box, including dates, details and symptoms leading up to it, to help avoid delays in processing your claim.
This claim is related to
For This claim is related to, check Accident, Illness or Wellness.
Veterinarian, Clinic Name and Is this claim an estimate for future treatment?
Enter the Veterinarian, Clinic Name, Phone and Fax. For Is this claim an estimate for future treatment?, check Yes or No.
Total amount claimed and Did any other veterinarian treat your pet?
Enter the Total amount claimed and the Date illness/injury first occurred. For Did any other veterinarian treat your pet?, check Yes or No.
Send payment to and Is this a new condition?
For Send payment to, check Me or Veterinarian. For Is this a new condition?, check Yes or No.
More rules for ASPCA Pet Health Insurance Claim Form
Please fill out this form completely. Incomplete forms will delay processing.
Please use only one claim form per pet for each accident or illness.
Visit any licensed veterinarian in the U.S. or Canada, including specialists and emergency clinics.
Call ASPCA Pet Health Insurance at 1-866-204-6764.
You can check the status of your claims easily online by signing into the free Member Center at my.aspcapetinsurance.com. In the Member Center, you can also sign up for direct deposit of claim payments.
Common questions about ASPCA Pet Health Insurance Claim Form
Who signs it?
Form U0314 - CS22: fill out this form completely and sign it. You don't need your veterinarian's signature. Sign under Signature of Pet Owner and enter the Date.
Is there a deadline?
Fax, mail or email your form with invoice(s) within 270 days of treatment.
Where do I file it?
Mail: ASPCA Pet Health Insurance 1208 Massillon Rd. Suite G 200 Akron, Ohio 44306 E-Mail: claims@aspcapetinsurance.com. If you use email, just scan and attach the form and invoice(s). Fax: 1-866-888-2495 no cover sheet necessary Please choose only one method. Duplicate claim submissions may delay processing.
Is there a penalty?
Any person who, with the intent to defraud or knowingly facilitates a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement, or conceals information for the purpose of Misleading may be guilty of insurance fraud and subject to criminal and/or civil penalties.
What am I certifying when I sign?
I confirm to the best of my knowledge the statements on this claim are true in every respect. I understand that the fees listed may not be covered or may exceed my plan benefit. I understand that I am financially responsible to my veterinarian for the entire treatment. I understand that this claim cannot be adjusted without itemized receipts. I also understand that the deliberate misrepresentation of the animal's condition or the omission of any material facts may result in the denial of the claim and/or the cancellation of coverage. I authorize United States Fire Insurance Company and its business partners to review and obtain a copy of ALL RECORDS including the insurance claim records and medical records as to examination, history, diagnosis, treatment and prognosis with respect to any condition. I further authorize these entities to disclose identifying information about me and my pet, as well as information about my claim experience, to my veterinarian.
Sources
[1] Claim Form (U0314 - CS22), ASPCA Pet Health Insurance (the Official source link on this page).
