The LC 7274 1 form, titled "Statement of Claim Association and Society Insurance Corporation," serves as a critical document for individuals needing to submit a TRICARE claim. It requires thorough completion by the member and necessitates the accompaniment of relevant medical bills, hospital bills, and all Explanation of Benefit worksheets from TRICARE. Moreover, it mandates claimants to supply a receipt evidencing the payment of the co-payment amount to the provider. Other vital information includes the insured's name, address, certificate number, marital status, and detailed patient and accident or illness information. Importantly, the form features an Assignment of Benefits section, authorizing the direct payment of eligible benefits related to the injury or illness to the care provider. A distinctive feature of this form is its emphasis on legal declarations tailored to the resident's state, highlighting the consequences of submitting false or misleading information, which range from criminal penalties to civil fines, depending on the jurisdiction. This underscores the importance of honesty and accuracy in the submission process, reflecting the legal and ethical standards expected in insurance claims.
| Question | Answer |
|---|---|
| Form Name | Form Lc 7274 1 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | po box 2510 rockville md 20847, association and society insurance corporation, Colorado, sssss |