Form Lc-7363-1 (Mlic) - Statement Of Claim And Instructions On How To Submit A Tricare/champva Supplement Claim

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P.O. Box 2510
Rockville, Maryland 20847-2510
1-800-638-2610
Underwritten by Monumental Life Insurance Company
STATEMENT OF CLAIM
INSTRUCTIONS ON HOW TO SUBMIT A TRICARE/CHAMPVA SUPPLEMENT CLAIM
1. The form must be completed by the Member and;
2. Send the appropriate medical bills, hospital bills and all Explanation of Benefits worksheets from TRICARE/CHAMPVA
to: Claims Department, Group Insurance Administrator, P.O. Box 2510 Rockville, Maryland 20847-2510
3. TRICARE Prime claimants must submit a receipt from the provider of care showing the paid co-payment amount.
Name of Member
Member ID#
Sex
Male
Female
Date of Birth
Social Security Number
Marital Status
Single
Married
Other___________________
Address (Street, City, State & Zip Code)
Name of Association/Organization/Credit Union/Employer
Type of Claim:
Prime
Standard
CHAMPVA
TRICARE
TRICARE
Name of Patient
Relationship to Member
Date of Birth
Spouse
Daughter
Son
Other
Address of Patient (Street, City, State & Zip Code)
Nature of Accident or Illness - Describe
Have you claimed benefits for this condition previously?
No
Yes If Yes, when? ________________
Assignment of Benefits
I hereby authorize payment of eligible benefits under my policy in connection with this injury or illness to:
Name of Provider of Care (Doctor, Hospital, etc.) ______________________________________________________________
_______________________________________
___________________________________
_______________
Signature of Patient or Guardian
Relationship to Patient if Signed by Guardian
Date
LC-7363-1 (MLIC)
Page 1 of 2
9/2012

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