Form Glc10115 - Wellness Benefit Claim Form printable pdf download

The Lincoln National Life Insurance Company, PO Box 82087, Lincoln, NE 68501-2087

toll free (877) 815-9256 Fax (877) 668-5331

WELLNESS BENEFIT CLAIM FORM

(BENEFITS MAY BE DELAYED IF CLAIM FORM IS NOT FULLY COMPLETED)

Please complete the information on the claim form below and submit a copy of the bill. If you were treated at a non-cost incurred facility,

please furnish verification from that facility of tests performed.

1. Employer Name: __________________________________________________________________________________________

2. Policyholder Name

: _________________________________________________________________________

(First, Middle, Last)

3. Policy Number: ________________________________________________

4. Claimant Name

: ____________________________________________________________________________

(First, Middle, Last)

5. Claimant Social Security Number: _________________________________

6. Claimant Birth Date

: _________________________________

(MM/DD/YY)

7. Address: _________________________________________________________________________________________________

City: ________________________________________________________

State: _______

Zip Code: __________________

8. Phone

: _______________________________________

(including area code)

e-mail Address: ___________________________________________________________________________________________

9. Please check the test(s) performed:

Date Test Performed

: ______________________

(MM/DD/YY)

h Abdominal Aortic Aneurysm Ultrasound

h EKG

h Blood Test for Triglycerides

h Double Contrast Barium Enema

h Bone Marrow Testing

h Fasting Blood Glucose Test

h Bone Density Screening

h Flexible Sigmoidoscopy

h Breast Ultrasound

h Hemoccult Stool Analysis

h CA 15-3

h Mammography

(Blood Test for Breast Cancer)

h CA 125

h Pap Smear

(Blood Test for Ovarian Cancer)

h Carotid Ultrasound

h PSA

(Blood Test for Prostate Cancer)

h CEA

h Serum Cholesterol Test to determine level of HDL and LDL

(Blood Test for Colon Cancer)

h Chest X-Ray

h Serum Protein Electrophoresis

(Blood Test for Myeloma)

h Colonoscopy

h Stress Test

h CT Angiography

h Thermography

10. Doctor’s Name: ___________________________________________________________________________________________

Doctor’s Phone: ______________________________________

Doctor’s Fax: _______________________________________

11. Doctor’s Address

: ____________________________________________________________________________________

(Street)

City: ________________________________________________________

State: _______

Zip Code: __________________

CERTIFICATION

Insured’s Name: ________________________________________________

Insured’s Social Security Number: _______________

I have checked the answers on this claim form and they are correct. I certify under penalty of perjury that my correct social security

number is shown on this form. I acknowledge that I have received the Claim Form Addendum, Fraud Warning and State Versions’ form

and that I read the statement required by the State Department of Insurance for my state, if my state was listed on the form.

_____________________________________________________________________

___________________________________

Insured’s Signature

Date

Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.

Page 1 of 3

GLC10115

4/12

Form Glc10115 - Wellness Benefit Claim Form

Related Articles

Related forms

Related Categories