V10 97 Claim Form – Fill Out and Use This PDF

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V10 97 Claim Form PDF Details

The V10 97 Claim Form is one of the most important documents you will use when filing a claim for benefits. This form is used to provide information about your claim and to request benefits from the VA. It is important to complete the form accurately and thoroughly so that the VA can process your claim as quickly as possible.

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Question	Answer
Form Name	V10 97 Claim Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	126
Avg. time to fill out	25 min 46 sec
Other names	central united life claim forms, central united life reimbursement form, central united claim form, central united life insurance claim form

12

Form Preview Example

CENTRAL UNITED LIFE INSURANCE COMPANY

INVESTORS CONSOLIDATED INSURANCE COMPANY

CLAIM FORM

CAUTION: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company files a statement of claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.

PART A TO BE COMPLETED BY PATIENT (INSURED)IMPORTANT: ALL QUESTIONS MUST BE COMPLETED AND FORM SIGNED


Insured’s Name						Social Security No.

Street Address			City or Town				State		Zip Code

Office Phone No.		Date of Birth		Marital Status				Sex: Male	!
								Female	!

IF A DEPENDENT CLAIM
Dependent’s Name				Date of Birth				Relationship

Are you entitled to an income tax exemption for this dependent? Yes ! No !
If child, is he/she employed?		Yes ! No ! Name of employer

Sex: Male ! Female ! If child is over 19 years old, is child a full-time student? Yes ! No !

Name of school

Are you or your dependent entitled to benefits under: Any other vision plan? Yes ! No !		Medicare Yes ! No !
If yes, name of family member holding policy			Policy No.
Name and address of employer, union, association, school, etc., carrying other plan

Name and address of other insurance company

PLEASE SIGN AND DATE AUTHORIZATION

I accept this claim form and authorize release of information relating hereto. I certify the truth of all personal information contained above and that all the services listed above have been completed/delivered. I agree to be responsible for the applicable co-payment as detailed in my Group program, for any services indicated as rendered. I also agree to be responsible for any and all services which may be rendered but not eligible for coverage under my Group Program.

Patient (Parent or Subscriber Signature)

Date

AUTHORIZATION TO PAY BENEFITS TO PROVIDER: I hereby authorize payment directly to the Provider of the Vision Benefits for the services as described on this claim but not to exceed the scheduled amount of covered vision care expenses for these services.

Insured Person (Signature)Date

TO BE COMPLETED BY AMERICAN STATES INSURANCE

Eligibility and status approved by Central United Life/Investors Consolidated Insurance Companies

Claims Administrator

Date

V-10/97

COMPLETE AND RETURN

THIS FORM PROMPTLY

Central United Life Insurance Company

Investors Consolidated Insurance Company

P.O. Box 925309

Houston, TX 77292-5309

CAUTION: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company files a statement of claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.

PART B TO BE COMPLETED BY PROVIDER

Name

Mailing Address

City, State, Zip

Soc. Sec. No. or E.I.N.

License No.

Phone No.

1. Is exam required as condition of employment?

Yes ! No !

2. Is exam the result of occupational injury? Yes ! No !

3. Is exam the result of auto accident? Yes ! No !

4. Other accident? Yes ! No !

If Yes to 1, 2, 3 or above, give brief description and dates

EXAMINATION

Description

Date

Code

Fee

Plan Allowance

Patient Responsibility

HAVE GLASSES BEEN PRESCRIBED? Yes ! No

!Description: ! Single Vision

! Bifocal ! Trifocal

Date

Code

Fee

Plan Allowance

Patient Responsibility

Bifocal/Trifocal Style:

Prescription:

Sphere

Cylinder

Axis

Prism

Base

Base Curve

R

L

BIFOCAL ADD

Height

Width

PUPILLARY WIDTH:

Reading

Distance

R

L

FRAMES: Mfg. Name & Style:

HAVE CONTACT LENSES BEEN PRESCRIBED? Yes ! No

!Description: ! Hard ! Soft ! Gas Permeable

Date

Code

Fee

Plan Allowance

Patient Responsibility

!Extended Wear ! Bifocal

Prescription:

Hard or Soft Daily Wear Contact Lenses

Base Curves Lens Rx	Lens Size	2nd Curve Width	P.C. Width	2nd. Curve Radius	P.C. Radius	O.Z.	Tint
R
L
Gas Permeable or Extended Wear Contact Lenses
Lens Rx	Lens Size	Type or Mfg.		Add		Seg. Hgt.
R
L
BIFOCAL CCL.		RAM
Bifocal Style		Crescent
		Curve Top
		One Piece

Manufacturer & Style #:

The services listed above are the only services considered for possible benefits under your vision care plan. Payment of these services is subject to current eligibility on the date services are completed/delivered.

I hereby certify that the services as indicated by the date listed have been completed/delivered and that the fees submitted are the actual fees charges and intended to be collected for these services. Payment is requested in accordance with the rules and regulations of The Health Application Network

Provider Signature	Date
PROVIDER signature Required

V-10/97

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The following parts are going to make up your PDF document:

portion of gaps in central united life vision

In the PLEASE, SIGN, AND, DATE, AUTHORIZATION Patient, Parent, or, Subscriber, Signature Date, Insured, Person, Signature Date, Claims, Administrator Date, COMPLETE, ANDR E, TURN and THIS, FORM, PROMPTLY field, note your information.

Finishing central united life vision stage 2

Indicate the important data in PART, B, TO, BE, COMPLETED, BY, PROVIDER Name, Mailing, Address City, State, Zip So, cSec, No, orE, IN License, No Phone, No EXAMINATION, Description, Date, Code, Fee, Plan, Allowance Patient, Responsibility Date, Code, Fee, Plan, Allowance Patient, Responsibility Prescription, and Sphere segment.

Filling out central united life vision part 3

Indicate the rights and obligations of the sides within the space FRAMES, M, fg, Name, Style BIFOCAL, CCL, Bifocal, Style and RAM, Crescent, Curve, Top, One, Piece

Completing central united life vision stage 4

Prepare the form by taking a look at all these sections: Date.

stage 5 to filling out central united life vision

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