Form 0000 Clm PDF Details

In today's world, there are many different types of software that you can use to create forms. However, when it comes to creating a form that is specific to your needs, the best option is often to create a custom form. In this blog post, we will discuss how to create a custom form in Microsoft Word using the FORM0000 CLM. We will also discuss some of the benefits of using a custom form. Stay tuned for more information!

QuestionAnswer
Form NameForm 0000 Clm
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesPrescription_Cl aim_Form psi international student health insurance form

Form Preview Example

MAIL TO:

CLAIM FORM

FIRST STUDENT

COMPLETE IN DETAIL

 

P.O. BOX 809025

TO INSURE

DALLAS, TEXAS 75380-9025

PROMPT HANDLING

Coverage Verified

NOTICE: Anyone who knowingly misrepresents or falsifies essential information requested

by this form may, upon conviction, be subject to fine or imprisonment.

❑ GRADUATE

 

-PLEASE PRINT ALL INFORMATION-

 

❑ UNDERGRADUATE

PART I - MUST BE COMPLETED BY STUDENT AND SIGNED

 

Name of College or University, City and State

 

Domestic

❑

Student ID Number

Birth Date

 

 

 

International

❑

 

 

Insured Student’s Name

 

 

 

 

 

 

 

LAST NAME

FIRST NAME

M.I.

 

SOCIAL SECURITY #

PHONE #

❑ Present Address

Street Address

❑Home Address

 

 

 

 

 

 

City

 

State

 

 

 

 

 

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLEASE MAIL ALL CORRESPONDENCE AND PAYMENTS TO THE ADDRESS ABOVE.

 

 

 

 

 

 

 

 

 

If claim for dependent, give dependent’s name

 

 

 

 

 

 

Relationship to Insured

Age

Sex

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMPLETED

 

Mother’s Name

 

 

 

 

 

 

 

Employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name and Address of Insurance Co.

 

 

 

 

 

 

 

 

 

 

 

 

 

Policy No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Father’s Name

 

 

 

 

 

 

 

Employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name and Address of Insurance Co.

 

 

 

 

 

 

 

 

 

 

 

 

 

Policy No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BE

 

Spouse’s Name

 

 

 

 

 

 

 

Employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name and Address of Insurance Co.

 

 

 

 

 

 

 

 

 

 

 

 

 

Policy No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MUST

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you covered (as an insured or dependent) by any other hospital and/or medical plan?

 

 

 

❑ Yes

❑ No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you filed a claim with any other insurance company?

❑ Yes ❑ No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Send copies of all Explanation of Benefits paid or denied to First Student at the above address.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

Date of accident or sickness.

 

 

Date of

first treatment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Indicate reason for medical treatment.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

If injury, describe how and when accident

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

occurred and indicate if work related.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

❑ Intramural

❑ Club

 

 

 

 

 

 

 

 

 

4.

If injured in play or practice of sport,

 

 

Check

 

 

❑ Intercollegiate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

indicate which sport.

 

 

One

 

 

❑ Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Have you previously been troubled

❑ Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

with this condition?

❑ No

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

Were you seen or referred by the

❑ Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

physician for this condition?

❑ No

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

Name and address of Provider,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

other than Student Health Service.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

Give names of all other physicians

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

consulted.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From:

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Hospitalized? If so where and what dates.

Where?

 

 

 

 

 

 

 

 

 

 

 

To:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PAYMENT WILL BE MADE TO THE PROVIDERS OF SERVICE, UNLESS A PAID RECEIPT IS ATTACHED AT TIME OF SUBMISSION.

To any medical care provider, medical care facility, insurer, government-sponsored health plan, or employer: I authorize the release of any medical information about me to Student Insurance. This applies to all information about the diagnosis, treatment, or prognosis of any illness or injury I now have or have had in the past. The Company will use this information to determine if my claim is eligible. Any information obtained will not be released by the Company except to my primary health insurance car- rier (if any) or persons or organizations performing investigative or legal services for the Company in connection with my claim. A copy of this authorization shall be considered as effective and valid as the original and shall remain in effect for one year from the date of authorization. I certify that the information given by me in sup- port of my claim is true and correct.

Patient’s or Authorized Representative’s Signature

 

 

 

Date

 

If Authorized Representative, Relationship to Patient

 

 

 

 

or Legal Designation

 

 

 

 

 

STREET

CITY

STATE

 

ZIP CODE + 4

ITEMIZED BILLS FOR MEDICAL EXPENSES MUST BE ATTACHED.

0000-CLM

Form 0000 Clm isn’t the one you’re looking for?

Related Documents