Veterinarian Reimbursement Release Form - Pets Best

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Veterinarian Reimbursement
Release Form
Questions?
Use this form only if you have not paid for your services and you want
 877.738.7237
your payment to be sent directly to your veterinarian (veterinarian
signature required).
1
YOUR INFORMATION
Policy Number:
Policyholder Name:
Pet Name:
2
CLAIM INFORMATION
Date(s) of Service:
Claim Number (if known):
3
POLICYHOLDER DECLARATION
By affixing my signature to this document, I hereby release any claim reimbursement for unpaid amounts on the attached
claim and request that any reimbursement be made directly to the veterinary hospital or clinic to which a balance is left owing
in my name. I understand that this request does not guarantee claim payment. Eligibility of all claims is determined at time of
review of the claim, and I am responsible for all outstanding balances.
X
Policyholder Signature
Date
4
VETERINARY CLINIC OR HOSPITAL DECLARATION
I understand that submission of the above referenced claim is not a guarantee of payment and that the decision to extend
credit to the above referenced policyholder is made without any such warranty or promise.
X
Authorized Veterinary Representative Signature
Date
Print Name
Print Hospital or Clinic Name
** To avoid delaying the processing of your claim, please complete sections 1-4. **
5
SUBMIT FORM
FAX
MAIL
ONLINE
866.777.1434
2323 S. Vista Ave., #100
/customerportal
Boise, ID 83705
Policies sold by Pets Best Insurance Services, LLC are underwritten by Independence American Insurance Company and American Pet Insurance
Company. To determine the underwriter in your state, please call Pets Best at call 1-877-738-7237.

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