Healthscope Medical Claim Form PDF Details

Are you a patient trying to get reimbursed for bills from your doctor's visit? The Healthscope Medical Claim Form is here to help simplify the process. This easy-to-use form allows patients to accurately submit their medical claim requests in order to seek reimbursement of medical bills that they have incurred. Whether you are a regular or one-time user, this helpful resource can assist with all your medical claims needs. Check out our blog post today and learn more about what information you'll need when filing a request on the Healthscope Medical Claim Form.

Form NameHealthscope Medical Claim Form
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namespayor, applicable, omit, Workmens

Form Preview Example


HealthSCOPE Benefits

P. O. Box 99006

Lubbock, TX 79490-9006

Medical Claim Form

Please refer to instructions on the back of this form. A properly completed form will expedite the processing of your claim.


Employee Social Security Number

Employee Name (Last, First, Middle)

Employee Marital Status

Single Divorced

Married Separated







Dependent Name (Last, First, Middle)

Relationship to Employee






If claim is for dependent child over age 19 at the time the claim was




incurred, was the dependent:

A student and/or financially



(if “B”, see instruction number 5 on the reverse side of this form)

dependent on you?








Name of Spouse / Dependent with other Coverage


Social Security Number

Plan Number

Name and Address of Other Carrier

Name and Address of Other Employer





How, when and where did the accident occur?




Did the accident happen during the course of employment?




If so, has a Workmen’s Compensation claim been filed?





Upon presentation of the original or a photocopy of this signed authorization, I authorize any medical professional, hospital or other medical-care institution, insurance support organization, pharmacy, governmental agency, insurance company, group poli- cyholder, employer or benefit plan administrator to provide HealthSCOPE Benefits, or an agent, attorney, consumer reporting agency or independent administrator acting on it s behalf, in formation concerning advice, care or treatment provided the patient, employee or deceased named below, including information relating to mental illness, use of drugs, or use of alcohol. I also au- thorize my employer, group policyholder or benefit plan administrator to provide HealthSCOPE Benefits, Inc. with financial or em- ployment-relation information.

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


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 full-time basis and is financially dependent on you for support, you may be required to pro- vide proof of attendance (tuition receipt or letter from school) reflecting full-time student status during the period in which the dependent was treated.

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 79490-9006