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.

Form NameBellevue Medical Claim Form
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namespo box 85008 bellevue wa 98015, APPLICABLE, MEDICARE, 800 869 7093

Form Preview Example

City of Bellevue LEOFF 1 Disability Board Medical Claim Form

LEOFF 1 Active/Retiree Information:

Name: ____________________________________________

Date of Birth:__________________________


SSN#: XXX-XX- __ __ __ __


State:_______ ZIP Code:_______________

Telephone Number:_________________________________


If claim is approved, check should be made payable and mailed to: _____________________________________


Reimbursement Request Information:

Service Date


Service Received

Medical Reason

Uncovered Cost

Total: $______________



Claimants Signature

Date Submitted

*Submission to the Disability Board must include the following:

Completed Disability Board Medical Claim Form.

Itemized statement from the service provider indicating any insurance payments or other payments made to the provider.

Insurance Carrier’s “Explanation of Benefits” (EOB) form and Medicare Statement for any claim submitted by a member covered by Medicare.

Provider Billing invoice if not covered by Insurance. Please provide explanation as to why this is a medical necessity (Medical Necessity is determined by the City of Bellevue Disability Board).

Submit this form with applicable receipts, statements and “Explanation of Benefits” (EOB) to:

City of Bellevue LEOFF 1 Disability Board

Human Resources

PO BOX 90012

Bellevue WA 98009-9012

Phone: 425-452-7198

H:\Retirement Services\Disability Board\Forms\2006 gmd

How to Edit Bellevue Medical Claim Form Online for Free

This PDF editor was developed to be as easy as possible. When you stick to the following actions, the procedure for preparing the 800 869 7093 file will be convenient.

Step 1: First of all, select the orange "Get form now" button.

Step 2: Now you are on the document editing page. You can edit, add content, highlight particular words or phrases, place crosses or checks, and put images.

If you want to fill in the template, type in the details the application will request you to for each of the appropriate areas:

entering details in ELIGIBILITY step 1

Please fill out the Claimants Signature, Date Submitted, Submission to the Disability Board, Total, Completed Disability Board, Itemized statement from the, Provider Billing invoice if not, and Submit this form with applicable field with the necessary data.

ELIGIBILITY Claimants Signature, Date Submitted, Submission to the Disability Board, Total, Completed Disability Board, Itemized statement from the, Provider Billing invoice if not, and Submit this form with applicable fields to fill out

You will be asked for some valuable information if you want to complete the City of Bellevue LEOFF Disability, and HRetirement ServicesDisability section.

stage 3 to filling out ELIGIBILITY

Step 3: Click "Done". Now you may export the PDF form.

Step 4: Attempt to create as many copies of your file as possible to prevent future issues.

Watch Bellevue Medical Claim Form Video Instruction

Please rate Bellevue Medical Claim Form

1 Votes
If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .