Trustmark Wellness Claim Form: A112-2507

Wellness Rider Claim (A112-2507) at a glance

What it is: The Wellness Rider Claim is the form on which you advise which routine service you had completed by providing the date it was completed.

Who signs: Claim Submission Signature is to be completed by Policy Owner. Be sure to sign and date this section of the form.

Section A & B are to be completed by Policy Owner. Complete these sections in full and return for review of benefits.

Complete a SEPARATE form for each individual and/or calendar year that you are claiming benefits.

What to bring and attach to Wellness Rider Claim (A112-2507)

Be sure to include the following required supporting documentation.

Proof of testing/services you had completed, such as copies of bills, invoices, explanation of benefits, treatment notes or test results that documents Date of test, Who test completed on and What specific test was completed.

A filled-in Wellness Rider Claim (A112-2507) example: a policy owner claims two routine services

How to fill out Wellness Rider Claim (A112-2507), box by box

Section A - Policy Owner Information

In Section A - Policy Owner Information, enter the Policy / Certificate #, Name, DOB, SSN, Address (Street, City, State, Zip Code) and Phone # with Home, Cell or Work marked, and the E-Mail Address. Mark Yes or No for Employee of Trustmark Companies? and English or Spanish for Language Preference.

Section B - Claim Information

In Section B - Claim Information, enter the Name of patient, DOB and SSN, and mark the Relationship to Policy Owner: Policy Owner, Spouse, Son/Daughter or Other.

Routine Services

Under Routine Service and Date Completed, the services listed are Routine Mammogram, Heart Exercise Test or Heart Stress Test, Breast Ultrasound, Stool DNA Test, Pap Smear for Women Over Age 18, Endoscopy of Lower Intestine, Colonoscopy, CA 15-3 (Blood test for breast cancer), Blood test for A1C, CA125 (Blood test for ovarian cancer), Blood test to determine Total, HDL & LDL Cholesterol, CEA (Blood test for colon cancer), Blood test for triglycerides, Serum Protein Electrophoresis (Blood test for Myeloma), Prostate Specific Antigen (PSA), Thermography, Chest X-ray, Bone Marrow Testing, Immunization/Vaccine with Please indicate for what, and Routine Physicals.

This is not a guarantee of payment. Benefits will be determined based on your policy provisions & the provisions of your Wellness Rider.

Claim Submission Signature

Under Claim Submission Signature, sign, print your name and date to certify to the accuracy of information provided, in the Policy Owner Signature, Print Name and Date lines.

Wellness Clinic or No Proof of Treatment

Wellness Clinic or No Proof of Treatment only needs to be completed if the claimed testing was part of a wellness clinic sponsored by your employer OR you have no documentation of the date & type of test provided. It is to be completed by the Medical Professional who completed the testing, with Signature of Medical Professional, Print Name and Date.

More rules for Wellness Rider Claim (A112-2507)

Incomplete or illegible answers may result in delay of benefits.

Keep a copy of all parts of this form and any supporting documentation for your records.

Optional: Third Party Communication Authorization is not required but completing it will provide better and faster communication with you or anyone you designate. It is to be completed by Policy Owner & Patient. Complete it if you would like to authorize Trustmark to discuss and/or release information to a third party, including a spouse, friend or agent. Policy Owner and Patient must give permission for disclosure of their information to each other, if applicable.

Disclosure Authorization is to be completed by patient unless patient is a minor or legally incapacitated. Be sure to sign and date this section of the form, including DOB & last 4 digits of SSN where indicated.

Enter the Insured's name (Patient) (Please Print) and Last 4 of SSN#. Sign the Patient Signature (or Policy Owner, if Patient is under 18), marking Signed by: Policy Owner or Patient, with Date Signed, Patient's Date of Birth and Relationship, if other than insured. This Authorization will be in force for the duration of the claim or up to 12 months from the date shown, whichever time period is less. If I revoke or fail to sign this authorization or alter its content it may affect the handling of my claim, including denial of benefits under my policy.

E-Sign Disclosure and Consent Notice is to be completed by Policy Owner. Be sure to sign & date this section.

Under PREFERRED METHOD OF COMMUNICATION, mark Text Messages and Email with a cell phone #, or Only Email with a confirmed email address.

Note texting as your preferred communication method if you would like to authorize Trustmark to alert you via text when any payment is process for this claim.

Common questions about Wellness Rider Claim (A112-2507)

Sources

[1] Wellness Rider Claim Form A112-2507 (2-20), Trustmark (the Official source link on this page).