Shelter Care Claim Form PDF Details

The Shelter Care Claim Form is a required form to be filed with the Nebraska Department of Health and Human Services when seeking reimbursement for providing emergency shelter care services. The form is used to document the number of days that the service was provided, as well as the number of individuals who received shelter care services. Completed forms must be submitted within 30 days of providing shelter care services. Reimbursement may be granted for up to 60 days of services per year, per household. The Shelter Care Claim Form is a required form to be filed with the Nebraska Department of Health and Human Services when seeking reimbursement for providing emergency shelter care services.

Below is the data relating to the file you were in search of to fill in. It will tell you the amount of time you will need to finish shelter care claim form, exactly what parts you need to fill in and a few further specific details.

QuestionAnswer
Form NameShelter Care Claim Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namessheltercare pet insurance claim form, shelter care insurance, BCS, insurer

Form Preview Example

Claim Form

Underwritten by Praetorian Insurance Company, NY

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 ollow the Claims 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

2

3

Date

of

ns and

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

 

 

 

 

 

$

Yes

No

When:

 

 

 

 

 

 

 

 

 

 

 

 

MM

DD

YY

 

 

 

 

MM

DD

YY

 

 

 

 

 

$

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: 1.866.369.7387

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 and I conm my understanding of the applicable fraud warning below.

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

P.O. Box 2150

medicals@pethealthinc.com

Bu, NY 14240-2150

 

Fax

 

1.866.369.7387

 

Questions:

 

Call our Customer Care Unit at

 

1.877.707.7297

 

 

 

Applicable in Alaska

A person who knowingly and with intent to injure, defraud, or deceive an insurance company osecuted under state law.

Applicable in District of Columbia

WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or an insurer may deny insurance beneelated to a claim was provided by the applicant.

Applicable in Alabama, Arkansas, Louisiana, Maryland, Rhode Island, Texas, Utah and West Virginia

Any person who knowingly presents a false or fraudulent claim for payment of a loss or beneesents false information in an application for insurance is guilty of a crime and may be subject to con

Applicable in Arizona

For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

Applicable in Kentucky, Michigan, New Jersey, New Mexico and Pennsylvania.

Any person who knowingly and with intent to defraud any insurance company or another person, ading, information

concerning any fact, material thereto, commits a fraudulent insurance act, which is a crime, subject to criminal prosecution and civil penalties. In DC, LA, ME, TN and VA insurance bene denied.

Applicable in California

For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to con

Applicable in Colorado

It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulator y Agencies.

Applicable in Delaware, Florida and Idaho

Any person who knowingly and with the intent to injure, Defraud, or Deceive any Insurance Company Files a Statement of Claim Containing any False, Incomplete or Misleading is Guilty of a Felony. * *In Florida – Third Degree Felony

Applicable in Hawaii

For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or bene

Applicable in Indiana

A person who knowingly and with intent to defraud an insurer .

Applicable in Minnesota

A person who er is guilty of a crime.

Applicable in Nevada

Pursuant to NRS 686A.291, any person who knowingly and willfully ning a material fact is guilty of a felony.

Applicable in New Hampshire

Any person who, with the purpose to injure, defraud or deceive any insurance company, osecution and punishment for insurance fraud, as provided in RSA 638:20.

Applicable in New York

Any person who knowingly and with intent to defraud any insurance company or other person ls for the purpose of

misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed thousand dollars and the stated value of the claim for each such violation.

Applicable in Ohio

Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or insurance fraud.

Applicable in Oklahoma

WARNING: Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

In the state of WA and all other states not mentioned above and Puerto Rico; it is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment,

Watch Shelter Care Claim Form Video Instruction

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