HEALTH INSURANCE CLAIM FORM

FOR MEDICARE CLAIMS: See the notice modifying system No. 09-70-0501, titled, ‘Carrier Medicare Claims Record,’ published in the Federal Register, Vol. 55 No. 177, page 37549, Wed. Sept. 12, 1990, or as updated and republished.

This form is for out-of-network claims ONLY, to ask for payment for eligible health care you have received. To ensure faster processing of your claim, be sure to do the following: If you write on the form, use black or blue ink and print clearly and legibly.

Looking for employer or broker forms? Here are some commonly used forms you can download to make it quicker to take action on claims, reimbursements and more.

b. OTHER CLAIM ID (Designated by NUCC) c. INSURANCE PLAN NAME OR PROGRAM NAME d. IS THERE ANOTHER HEALTH BENEFIT PLAN? YES NO If yes, complete items 9, 9a and 9d. 13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below. SIGNED 16.

submits an enrollment form for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto may have violated state law.

Browse commonly requested forms to find and download the one you need for various topics including pharmacy, enrollment, claims and more.