Bellevue Medical Claim Form – Fill Out and Use This PDF

Bellevue Medical Claim Form PDF Details

For individuals affiliated with the City of Bellevue's Law Enforcement Officers' and Fire Fighters' (LEOFF) Disability Board, understanding the Bellevue Medical Claim Form is essential. This comprehensive form serves as a critical tool for active or retired members seeking reimbursement for medical expenses not covered by insurance. It requires detailed information, including personal details such as name, date of birth, address, and social security number, as well as specifics about the medical service received, including the date of service, provider, medical reason for the service, and the uncovered costs. Additionally, the form provides guidance on making the reimbursement check payable, something particularly useful for claimants. The process mandates the submission of several documents alongside the Bellevryue Medical Claim Form, such as an itemized statement from the service provider, an Insurance Carrier’s Explanation of Benefits (EOB), a Medicare statement if applicable, and a provider billing invoice in cases not covered by insurance, with an explanation of medical necessity as determined by the Disability Board. This thorough and structured approach ensures that all necessary information and documentation are provided to facilitate the review and processing of claims, highlighting the City of Bellevue's commitment to supporting its LEOFF 1 members in managing their medical expenses efficiently. Submission details, including the mailing address and contact information for the Disability Board, are succinctly outlined, making it easier for claimants to navigate the submission process successfully.