105/hra Claim Form - Consociate printable pdf download

105/hra Claim Form - Consociate

105/HRA Claim Form

Employer Name ________________________________________________________________________________________

Employee’s Name ______________________________________________________________________________________

Member ID Number _____________________________________________________________________________________

Dependent’s Name (if applicable) ________________________________________________________________________

Date of Service _________________________________________________________________________________________

Provider _______________________________________________________________________________________________

Amount Requested _____________________________________________________________________________________

Filing Instructions:

When filing a claim, you must attach copies of the Explanation of Benefits (EOB). Please be sure to number each

attachment page (i.e., Page 2 of 3, Page 3 of 3, etc.)

If you choose to mail your claim with the EOB, remember to keep a copy of the claim form and supporting documents

for your records.

MAIL TO:

Consociate

2828 North Monroe Street

P .O. Box 1068

Decatur, Illinois 62526-1068

If you choose to fax your claim with the EOB, please do not follow-up with a hard copy in the mail.

Remember to keep the original claims form and supporting documents for your records.

FAX TO:

217.233.2281

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105/hra Claim Form - Consociate