The HCCmis Claimants Statement and Authorization Form is used to provide information about the claimant's eligibility for Medicaid. The form must be completed by the claimant, their authorized representative, or an authorized provider. The information provided on the form will help determine whether the claimant meets Medicaid program requirements. Completing the form accurately is important, as it will help ensure that the claimant receives any benefits they may be entitled to.
| Question | Answer |
|---|---|
| Form Name | Claimants Statement And Authorization Form Hccmis |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | claimant's statement, claimants statement authorization, statement of authority form, csacliam com |
CLAIMANT’S STATEMENT AND AUTHORIZATION
(See reverse side for Directions for Submitting a Claim)
HCC Medical Insurance Services
Box No. 2005
Farmington Hills, MI
PART A: Complete for all claims. **All Checks and Correspondence Will Be Sent To The Address Below** |
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Insured Name: |
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Claimant (Patient) Name: |
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Sex: |
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Birthdate: |
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Sex: |
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Birthdate: |
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Home Telephone: |
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Mailing Address (include Street Address, City, State, Country, and |
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Work Telephone: |
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Postal Code): |
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Fax Number: |
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Plan Number: |
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Certificate Number: |
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1. |
Citizenship of Claimant: ________________________ Home Country of Claimant: ________________________ |
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(Country where you principally reside & receive regular mail) |
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Country Visited: _______________________________ |
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(HCCMIS may request a copy of your passport) |
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2. |
Is the Claimant:A |
Yes No |
If yes, please provide the name and address of |
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school:______________________________________________________ |
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3. |
Is the Claimant: |
Employed? |
Yes No |
If yes, please provide the name and address of |
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employer:___________________________________________________________
4.Do you or any family members have other coverage (medical, indemnity or liability) which might help cover hospital and medical expenses? Yes No If yes, please provide the following:
Name of Company: |
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Address: |
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Policyholder: |
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Policy Number: |
Is this group insurance? |
Yes No |
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PART B: Complete for new claims. If you need additional space, please attach additional sheets.
1.How did the condition begin? State fully all symptoms and describe the condition in detail from the beginning:
2.When did the first symptoms of this condition begin? State the exact date, if possible: (If due to an accident, please complete accident questionnaire, see Part C- DIRECTIONS)
3.Have you ever had or been treated for the same kind of illness or injury? Yes No If Yes, when? Name, address and telephone number of attending physician:
4.Name, address and telephone number of family physician (even if not consulted):
5.What ailments, diseases, illnesses, conditions or injuries have you had during the last five years? Please provide name and/or description of each condition, dates involved, and the name, address and telephone numbers of attending physicians:
CSA (CF) 02/13
PART C: Complete for all claims.
I verify that all information contained in this form is true, correct and complete to the best of my knowledge. I authorize any licensed doctor, practitioner of the healing arts, hospital, clinic, health related facility, pharmacy, government agency, insurance company, group policyholder, employee or benefit plan administrator having information as to the care, advice, treatment, diagnosis or prognosis of any physical or mental condition, or the financial or employment status of the insured named below, to provide this information to HCC Medical Insurance Services. I understand that I have the right to receive a copy of this authorization upon request. A copy of this shall be as valid as the original. This authorization is valid for twelve months from the date signed:
Signature of Insured:
Print Name:
Date:
Signature of Patient:
Print Name:
Date:
ASSIGNMENT OF BENEFITS AUTHORIZATION: I authorize payment of medical benefits to the doctor or other supplier of services submitting the attached bills.
Signature of Insured:
Date:
DIRECTIONS FOR SUBMITTING A CLAIM
1.If this is a new claim, complete ALL PARTS of this form.
2.If this claim is a result of an accident, please visit www.hccmis.com, “Downloads” to obtain the ACCIDENT QUESTIONNAIRE, or contact our office to request the form.
3.If this is a continuing claim, complete Parts A and C only.
4.Attach all original itemized bills for services and supplies. Please verify that the documents indicate your name, date of service, diagnosis and the charge for each service.
5.Mail to: HCC Medical Insurance Services
Box No. 2005
Farmington Hills, MI
6.If you have any questions, call
INDIANA LAW REQUIRES US TO NOTIFY YOU OF THE FOLLOWING: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete or misleading information commits a felony.
CSA (CF) 02/13