Patient Claim Form
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1
2Claim Form
USE SEPARATE FORM FOR EACH PATIENT
General instructions:
Make sure you and your physician or other health care professional fill out this form
completely in order for you to receive timely reimbursement for paid medical services.
Type or print requested information.
GROUP NO. (FROM SIHO I.D. CARD)
Ask your provider(s) to help you complete all information in sections C and D.
Attach itemized receipts or claim forms for each service. (Do not staple items.)
A separate reimbursement request form should be completed for each patient.
Please keep a copy of each itemized bill or receipt for your records.
MEMBER IDENTIFICATION NO. (FROM SIHO I.D. CARD)
Do not submit a form if your physician or other health care professional is also filing a claim to SIHO for the
same service.
A. PATIENT INFORMATION
PATIENT NAME (Print)
SEX
M
F
BIRTHDATE
RELATIONSHIP TO EMPLOYEE :
SELF
CHILD
SPOUSE
OTHER
B. EMPLOYEE INFORMATION
EMPLOYEE NAME
Check if new address
EMPLOYEE ADDRESS______________________________________________________City______________________________State_________ Zip____________
C. PROVIDER INFORMATION
PROVIDER NAME______________________________________________________TAX ID NUMBER__________________NPI NUMBER____________________
PROVIDER ADDRESS_____________________________________________________City______________________________State_________ Zip____________
D. SERVICE INFORMATION
Date (mm/dd/yy)
Place of Service
Codes for procedures,
Diagnosis Code
Charges
Number of Units
services or supplies
Total Charges
Amount paid by you
Over
(please complete both pages)
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Parent category: Legal