Claim Form - Compass Benefits Group printable pdf download

CLAIM FORM

GeoVisions

US00160580

NAME OF GROUP: ____________________________________________________________ POLICY NUMBER: ______________________________________________

Complete the information below. Make sure form is fully completed and signed before submitting. Always keep copies of all documents for claims.

PARTICIPANT’S LAST NAME

PARTICIPANT’S FIRST NAME

PARTICIPANT’S U.S. MAILING ADDRESS

(STREET)

(CITY)

(STATE)

(ZIP)

PARTICIPANT’S DATE OF BIRTH

PARTICIPANT’S GENDER

PARTICIPANT’S ID NUMBER

PARTICIPANT’S PHONE NUMBER

❑

(MM/DD/YY)

FEMALE

❑

MALE

If patient is a Dependent currently insured under this plan, complete information below (in addition to the above).

PATIENT’S LAST NAME

PATIENT’S FIRST NAME

PATIENT’S U.S. MAILING ADDRESS

(STREET)

(CITY)

(STATE)

(ZIP)

PATIENT’S DATE OF BIRTH

PATIENT’S GENDER

PATIENT’S PHONE NUMBER

❑

(MM/DD/YY)

FEMALE

❑

MALE

SECTION 1 – TYPE OF CLAIM

1. Is this claim pertaining to a sickness/medical condition or injury (which may include prescription medication), or for prescription reimbursement only? Check one:

❑ Prescription Reimbursement Only. Please complete SECTION 4 and SECTION 5.

❑ Sickness/ medical condition. Please complete SECTION 3, SECTION 4 and SECTION 5.

❑ Injury. Please complete SECTION 2, SECTION 4, and SECTION 5.

SECTION 2 – INJURY INFORMATION

1. Date that injury occurred: _________________________________________ When was physician first consulted? _______________________________________

2. Briefly describe type of injury (i.e., ankle sprain, broken arm, etc.) and how and where injury occurred: _________________________________________________

____________________________________________________________________________________________________________________________________

3. Was the injury the result of a motor vehicle accident? No ❏ Yes ❏

4. Did the injury occur while at your place of work? No ❏ Yes ❏ If yes, please list name and address of employer:

____________________________________________________________________________________________________________________________________

SECTION 3 – SICKNESS INFORMATION

1. Briefly describe sickness or medical condition: _______________________________________________________________________________________________

2. Have you suffered same or similar condition before? No ❏ Yes ❏ If yes, and you were previously treated for it, date treated: _____________________________

a) Name and address of physician who treated you: _______________________________________________________________________________________

3. If hospitalized at that time, date confined to hospital: _________________________________________________________________________________________

b) Name and address of hospital: ______________________________________________________________________________________________________

SECTION 4 – OTHER INSURANCE INFORMATION

1. Do you have other insurance that covers your condition (group, individual, automobile, medical, or liability)? No ❏ Yes ❏

If yes, who is the Policyholder? Self ❏ Parent ❏

Spouse ❏

Name of Insurance Carrier: ________________________________________________________

Member No.: ________________________ Group No.: ________________________________ Insurance Co. Phone No.: _______________________________

Primary Insured’s Name (Parent/Spouse): __________________________________________________________________________________________________

SECTION 5 – ASSIGNMENT OF BENEFITS

1. Indicate below to whom payment is to be made:

❑ Balance is owed to the provider of service. Please pay the provider as indicated on billing statement.

❑ Expenses have been paid by the patient/participant. Please reimburse the patient/participant listed above.

To any medical care provider, medical care facility, insurer, government-sponsored health plan, or employer: I permit (while my claim is pending) the release of any medical

information about me to the Company and its representatives. The Company’s representatives include reinsuring companies and other persons or groups performing

business of legal services relating to my claim. This applies to all information about the diagnosis, treatment, or prognosis or any illness or injury I now have or have had in

the past. The Company will use this information to find out if my claim is eligible. A copy of this authorization (one of which will be given to me by the Company upon my

request) will be as valid as this one.

I certify that the above information given by me in support of this claim is true and correct.

Patient’s or Participant’s Signature ________________________________________________________________________________ Date _______________________

IMPORTANT: This form must be completed and returned to the company within 60 days from the date of treatment, accompanied by all bills incurred to that date. Please

include itemized bills. See reverse side for itemized bill requirements.

Personal Insurance Administrators, Inc., P.O. Box 6040, Agoura Hills, CA 91376-6040

MAIL COMPLETED FORM TO:

SEE PAGE 2 FOR DETAILED INFORMATION ON THE CLAIMS PROCESS.

FORM FSG-GEOV-15

04/15