Pet Health Care Proxy Form Details

A pet healthcare plan claim form is an important document to have when seeking reimbursement for veterinary services. The form can be used to seek reimbursement from your pet health insurance provider for the costs of treatment your pet has received. By completing the form correctly, you can ensure that you receive the maximum reimbursement possible for the costs of your pet's care. Make sure to include all relevant information on the form, including the date and type of service provided, as well as the amount you are requesting for reimbursement. Keep a copy of the form for your records, and submit it to your insurance company as soon as possible after receiving treatment for your pet.

Below is the details concerning the form you were seeking to fill in. It will tell you the amount of time you will require to complete pet healthcare plan claim form, exactly what fields you will have to fill in, etc.

QuestionAnswer
Form NamePet Healthcare Plan Claim Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameshealthy pets insurance claim form, healthy pets claim form pdf, akc pet healthcare plan claim form, petfirst healthcare claim form

Form Preview Example

Pet Healthcare Plan

CLAIM FORM

Ph: 1.866.725.2747 Fax: 1.919.859.8193

For office use only

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SECTION -1-

This claim form must be filled out completely, and you must attach your itemized invoice. Incomplete forms will be returned.

Owner & Pet Information - This section to be completed by the policyholder

Last Name: _______________________________ First Name: ___________________ Policy Number: ___________________

Street: ________________________________ City & State: ______________________, _____ Zip Code: ___________

Phone Number: ________________________ Email Address: _______________________________________________

Check here and update above if you have new contact information

Name of Pet: _______________________________________________________________________________________

Call Name: _________________________________________________________________________________________

Breed: _____________________________________________ Sex: _____________ Age: ______________

First Date of Injury, Illness or Condition: __________________________________

Please provide a brief description of illness/injury/condition:

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POLICYHOLDER DECLARATION: I confirm that all details provided herein are true and accurate. I understand that I am financially responsible to the Veterinarian for the entire treatment. I also understand that the deliberate misrepresentation of the animal’s condition or

the omission of any material facts may result in the denial of the claim and/or the cancellation of coverage. I authorize the insuring company and its authorized representatives to review and obtain a copy of all records including the insurance claim records and medical records as to the examination, history, treatment and prognosis with respect to any condition. I understand that all charges from my

Veterinarian may not be covered or may exceed my plan benefits.

 

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Policyholder Signature (REQUIRED)

Date

 

 

SECTION -2- Please have your Veterinarian provide information pertaining to the invoices submitted with this claim.

THIS SECTION TO BE COMPLETED BY THE VETERINARIAN (REQUIRED)

Date of Treatment

Treatment

Diagnosis

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Length of time pet has been registered at your practice? ___________Has the pet been treated for a related problem? Yes/No

If yes, please provide detailed information of the treatment or any related conditions:

______________________________________________________________________________________________________________

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Name and phone number of previous or referring Veterinarian: ____________________________________________________________

VETERINARIAN DECLARATION: I certify that to the best of my knowledge all the information contained on this form is correct. I also understand it is a criminal act to assist in the preparation or presentation of a false or fraudulent claim under an insurance policy.

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Signature

Print Name

Date

 

 

 

Get it, File it, Send it!!

HOW TO GET A CLAIM FORM

Download a claim form from www.akcphp.com

Call Customer Service at 1.866.725.2747

E-Mail us at customer.service@petpartnersinc.com and request a claim form

HOW TO FILE YOUR CLAIM

Filing a claim under the Pet Healthcare Plan is simple and straightforward.

Complete Section 1 of the claim form, and have your Veterinarian complete Section 2 (remember, incomplete forms will be returned without processing).

Include your itemized invoice for all services.

Submit your claim for reimbursement.

Once your claim is completed you will receive a claims explanation of benefits explaining how your claim was processed.

**Remember to file your claim form and itemized receipts within the required timely filing limit.

3 EASY WAYS TO SEND FORMS

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919-859-8193Pet Healthcare Planclaims@petpartnersinc.com P.O. Box 37940

Raleigh, NC 27627-7940

Fraud Warning:

Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and may subject such person to criminal and civil penalties.

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