In today's healthcare landscape, navigating the intricacies of medical claim forms is paramount for the timely and efficient processing of healthcare benefits. Among these, the Healthscope Medical Claim Form stands as a critical document designed to streamline the reimbursement process for medical services rendered. Tailored to facilitate the submission of claims, this form requires comprehensive details covering all aspects of medical services—ranging from personal identification to specific information concerning the nature of medical treatments or accidents. By submitting the claim to HealthSCOPE Benefits at the provided address, individuals ensure that their claims are processed efficiently. The form underscores the necessity for meticulous completion, including the requirement of itemized bills and, if applicable, an Explanation of Benefits (EOB) from primary carriers. Furthermore, it accommodates different scenarios, such as claims for dependents, accidents, and instances necessitating authorization for the release of medical or employment-related information, highlighting the form’s versatility in addressing varied healthcare claims. The act of signing the form manifests the claimant's acknowledgment of its accuracy and grants permission for HealthSCOPE Benefits to access needed information to evaluate the claim. It underscores the form's central role in the claims process, facilitating communication between patients, healthcare providers, and insurance administrators to ensure that claims are resolved in a timely manner.
| Question | Answer |
|---|---|
| Form Name | Healthscope Medical Claim Form |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 9 |
| Avg. time to fill out | 2 min 18 sec |
| Other names | policyholder, Workmens, payor, Lubbock |
MAIL COMPLETED CLAIM FORM TO:
HealthSCOPE Benefits
P. O. Box 99006
Lubbock, TX
Medical Claim Form
Please refer to instructions on the back of this form. A properly completed form will expedite the processing of your claim.
I.COMPLETE FOR ALL MEDICAL CLAIMS
Employee Social Security Number |
Employee Name (Last, First, Middle) |
Employee Marital Status
Single Divorced
Married Separated
II. |
COMPLETE FOR DEPENDENT CLAIMS ONLY |
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Dependent Name (Last, First, Middle) |
Relationship to Employee |
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If claim is for dependent child over age 19 at the time the claim was |
Disabled? |
Yes |
No |
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incurred, was the dependent: |
A student and/or financially |
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(if “B”, see instruction number 5 on the reverse side of this form) |
dependent on you? |
Yes |
No |
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Name of Spouse / Dependent with other Coverage |
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Social Security Number |
Plan Number |
Name and Address of Other Carrier |
Name and Address of Other Employer |
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III. COMPLETE FOR ACCIDENTS ONLY |
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How, when and where did the accident occur? |
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Did the accident happen during the course of employment? |
Yes |
No |
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If so, has a Workmen’s Compensation claim been filed? |
Yes |
No |
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IV. COMPLETE FOR ALL MEDICAL CLAIMS (Authorization)
Upon presentation of the original or a photocopy of this signed authorization, I authorize any medical professional, hospital or other
I understand that HealthSCOPE Benefits will use such information for the purpose of evaluating my claim for benefits and that I or any authorized representative will receive a copy of this authorization upon request.
This authorization is valid from the date signed for the duration of the claim. I agree that a photographic copy of this authorization shall be valid as the original.
It is a crime to complete this form with information that you know is false, or to omit any facts that you know are
Patient Signature (if over 18 years of age) |
Date Signed (Mo/Day/Year) |
Employee Signature (if over 18 years of age) |
Date Signed (Mo/Day/Year) |
I authorize payment of medical benefits to the provider whose bills are attached.
_______________________________
Employee Signature
(OVER)
Medical Claim Form Instructions
1.Use a separate claim form for each family member. If the bill shows expenses for more than one family member, highlight the name of the patient for whom this claim is being submitted.
2.Complete the applicable Sections of the claim form for each claim.
3.All bills must be itemized and include the patient’s name, date of service, amount charged for service and diagnosis. Expenses may be submitted by having your doctor complete an At- tending Physician’s Statement, which your doctor will provide. Do not submit photocopies, cash register receipts or cancelled checks. Make copies of all claims before they are submitted. Claim personnel cannot provide copies.
4.If HealthSCOPE Benefits, Inc is not the primary carrier for this claim, submit an original Ex- planation of Benefits (EOB) from the primary payor and copies of the bills. Claims cannot be processed without the other plan’s EOB.
5.If the claim is for a dependent age 19 or older who attends an educational institution on a
6.Payments are made to you unless indicated on the claim form. If you want benefits paid di- rectly to a provider, sign your full name on the front of this form (bottom right hand side).
7.Sign and date the front side of this form (bottom left hand side), indicating the information provided is correct and authorizing release of information necessary to process this claim.
8.Submit claims with this claim form to:
HealthSCOPE Benefits
P. O. Box 99006
Lubbock, TX