Claim Information Form - United Healthcare
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1CLAIM INFORMATION FORM
For Use Only With Policies Underwritten by Student Resources (SPC) Ltd.
INSURED INFORMATION
Last Name:
First Name:
Middle Initial:
SR ID#(refer to your ID card):
Home phone #:
Date of Birth (mm/dd/yy):
Email address:
(
)
/
/
U.S. Mailing address:
P.O. Box:
City:
State:
ZIP Code:
PATIENT INFORMATION
(IF DIFFERENT FROM INSURED)
Last Name:
First Name:
Middle Initial:
U.S. Mailing address:
P.O. Box:
City:
State:
ZIP Code:
Home phone #: (
)
Date of Birth
:
(mm/dd/yy)
Patient’s relationship to student:
Self
Spouse
Child
Other
(please explain)
ACCIDENT INFORMATION
Auto
IC Sport
Intramural Sport
Interscholastic Sport
Work
Other
Type of Accident:
Date Occurred:
Type of Sport (Football, track, etc.):
Details of Accident:
INJURY / SICKNESS INFORMATION
Yes
No If Yes, and if you were treated for it, please provide information:
Have you suffered the same or a similar condition in the past?
Physician’s Name:
Physician’s Address:
Date Treated:
I hereby authorize any physician, hospital, or other medical provider to release any information regarding the medical history, treatment, or
benefits payable for this claim to United Healthcare Insurance Company. A photocopy of this authorization shall be as valid as the original.
Insured’s Signature:
Date:
OTHER INSURANCE INFORMATION
Is the patient covered by another insurance plan? Yes
No
If you checked “Yes”, please complete the section below.
Name of person carrying other insurance:
Subscriber #:
Name of other insurance carrier:
Other Insurance Policy #:
Other Insurance Phone #:
Policyholder Date of Birth(
):
mm/dd/yy
Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or
misleading information may be subject to criminal and/or civil penalties.
Insured’s Signature:
Date:
STUDENT HEALTH CENTER REFERRAL
A Referral was received:
Health Center Closed:
This was an Emergency:
I was more than 50 miles from campus:
Other (please explain):
Yes
No
Yes
No
Yes
No
Yes
No
Guidelines for Submitting Claims to UnitedHealthcare StudentResources
Bills must include diagnosis code, procedure code, service date and cost. Clip, do not staple, all bills to this completed form.
For prescription claims, provide receipt or computer printout from the Pharmacy which includes Medicine name, date dispensed and price with
your name, address and SR ID#. A claim form is not required.
Mail claim to: UnitedHealthcare StudentResources , P. O. Box 809025, Dallas, TX 75380-9025 (This is listed on your ID card)
Fax claim to: 469-229-5625
Email : A scanned copy of the completed form to
SRSPCLTD
Claim Form 06262013
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