Petcare Claim Form PDF Details

Embarking on the journey of a Petcare Claim can seem daunting at first glance, but armed with the right knowledge, it transforms into a straightforward process. This claim form, underwritten by Northbridge General Insurance Corporation, serves as a bridge between pet owners and insurance benefits, ensuring that our furry friends receive the care they need without undue financial stress on their families. Key to a smooth claim process is the meticulous completion of all sections of the form. This includes providing comprehensive details about the pet and the owner, attaching a detailed paid itemized invoice, and the pet's complete medical history from both current and previous veterinary clinics. The goal is to avoid any delays in processing, which means including everything from the policy number and contact information to the necessary medical records and veterinarian notes. The form also emphasizes the importance of the treating veterinarian's diagnosis and details about the claim, reinforcing the need for accuracy and clarity in every section. Moreover, it underscores the criticality of honesty and transparency through the policyholder and veterinarian declarations to prevent possible claim denials due to omissions or misrepresentations. With these elements in place, submitting a Petcare Claim becomes a structured and efficient process, designed to support pet owners during times when their pets need it the most.

QuestionAnswer
Form NamePetcare Claim Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespet watch claim, pet care emergency authorization form, pet watch claim form, petcare form printable

Form Preview Example

Claim Form

Underwritten by Northbridge General Insurance Corporation

INSTRUCTIONS: Please complete ALL sections on this form and submit with your paid itemized invoice and pet’s medical history. Only one claim form per pet. A complete veterinary medical history (records) from both current and previous veterinary clinics is required to process your pet’s

Checklist to avoid delays in processing.

Claims Checklist

Complete Section 1 About You and Your Pet

Include your Policy Number

Include your Contact Information

Review your Policy Documents and Terms and Conditions to see if coverage is available for the current medical condition you are claiming for

Have the treating veterinarian complete Sections 2 and 3

Sign your claim form in the Declarations Section (Section 3) Attach detailed paid invoices for condition(s) you are claiming for

*Missing information, signatures, or required supporting documents will result in delays in processing your claim

Medical Records Include:

Detailed examination or SOAP notes

Lab/pathology/radiology reports

Medical reports from referral or emergency hospitals

Transaction histories and invoices are not accepted

Invoices Must Be:

Detailed and Itemized indicating the cost and treatment Paid, unless reimbursement is to be made and agreed to by the veterinarian Account Summaries are not accepted

SECTION 1A: Your Pet’s Information

Policy Number:

Pet Name:

 

 

 

Species: Dog

Cat

Breed:

 

Age:

 

 

SECTION 1B: Your Information

Your Name:

Mailing Address:

Email Address:

Home Number:

Cell Number:

Check here if there has been a change to your address or phone number

SECTION 2: About Your Claim To be completed by the treating licensed Veterinarian

Diagnosis

List each separate diagnosis clearly

1

Date

of

 

 

Total amount

Has this medical condition been

 

symptoms (as noted by you, the

being claimed:

treated previously?

 

 

client or the pet’s medical record)

 

 

 

 

 

 

 

 

 

 

 

 

$

Yes

No

When:

 

 

 

 

 

 

 

 

 

 

MM

 

DD

YY

 

 

 

 

MM

DD

YY

2

$

Yes

No When:

MM

DD

YY

MM

DD

YY

3

$

Yes

No When:

MM

DD

YY

MM

DD

YY

 

 

 

 

 

 

Veterinarian Notes Please also attach veterinary history, radiology, pathology reports, and consultation notes where applicable

Pet’s Weight:

 

KG

LB Body Condition Score (BSC):

 

 

 

1-5 Scale (1=Emaciated, 5=Obese)

1-9 Scale (1=Emaciated, 9=Obese)

When was this pet registered with your practice?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM DD YY

If this pet was referred to you, please give the name of the referring practice:

SUBMIT A CLAIM

Email medicals@pethealthinc.com

Fax: 1.866.368.7387

Continue to Page 2

 

 

 

 

SECTION 3: Declarations

Policyholder Declaration

Veterinarian Declaration

I declare that my veterinarian recommended the treatment for which I am claiming. The veterinary clinic has completed Section 2 and the particulars given are correct to the best of my knowledge and belief. I agree that my veterinarian may provide information that the company may require to verify a claim. I understand that any misrepresentation or omission of any material fact can result in denial of the claim.

I declare that diagnosis and particulars given in Section 2 in regards to the treatment of this pet are correct to the best of my knowledge and belief. I agree to provide information that the company may require to verify a claim. I understand that any misrepresentation or omission of any material fact can result in denial of the claim.

Signature of Policyholder

Signature of Veterinarian

Date:

Print Veterinarian Name:

MM DD YY

Date:

MM DD YY

Please submit completed claims by:

CLINIC STAMP

Mail

Email

710 Dorval Drive, Suite 400

medicals@pethealthinc.com

Oakville, Ontario L6K 3V7

 

Fax

 

1.866.368.7387

 

Questions:

Call our Customer Care Unit at 1.866.275.7387

How to Edit Petcare Claim Form Online for Free

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Step 1: Simply press the "Get Form Button" at the top of this site to get into our pdf form editing tool. There you will find everything that is needed to work with your file.

Step 2: As soon as you launch the PDF editor, you will get the document made ready to be completed. In addition to filling in different blank fields, you can also perform various other things with the form, such as writing your own words, changing the initial textual content, adding graphics, placing your signature to the document, and more.

In an effort to fill out this form, be sure to type in the right information in each and every blank:

1. You should complete the pet watch claim accurately, thus be careful while working with the segments including these particular fields:

Learn how to complete pet care emergency authorization form stage 1

2. Once your current task is complete, take the next step – fill out all of these fields - Mailing Address, Email Address, Home Number, Cell Number, Check here if there has been a, SECTION About Your Claim To be, Diagnosis List each separate, Date of cidrst clinical signs and, Total amount being claimed, Has this medical condition been, MM DD YY MM DD YY MM DD YY, Yes No When, MM DD YY, Yes No When, and MM DD YY with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Tips on how to fill out pet care emergency authorization form portion 2

A lot of people frequently make mistakes when completing SECTION About Your Claim To be in this part. You should double-check whatever you type in right here.

3. The following segment will be about Pets Weight, KG LB Body Condition Score BSC, Scale Emaciated Obese Scale, When was this pet registered with, If this pet was referred to you, MM DD YY, SUBMIT A CLAIM, Email medicalspethealthinccom, Fax, and Continue to Page - complete all of these blanks.

Stage number 3 in submitting pet care emergency authorization form

4. To go forward, this part involves completing a handful of blanks. Examples include I declare that my veterinarian, Signature of Policyholder, Date, MM DD YY, Signature of Veterinarian, Print Veterinarian Name, Date, MM DD YY, Please submit completed claims by, CLINIC STAMP, Mail Dorval Drive Suite Oakville, Email medicalspethealthinccom, Fax, and Questions Call our Customer Care, which are key to moving forward with this process.

Signature of Policyholder, Mail Dorval Drive Suite Oakville, and Signature of Veterinarian in pet care emergency authorization form

Step 3: Make certain your information is accurate and then click "Done" to continue further. Obtain your pet watch claim when you sign up for a 7-day free trial. Immediately gain access to the pdf form from your personal cabinet, together with any modifications and changes all preserved! With FormsPal, you can easily complete forms without stressing about personal data incidents or entries getting shared. Our secure system makes sure that your private details are maintained safe.

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