Accident Proof Of Loss Claim Form - Babe Ruth League, Inc. printable pdf download

BABE RUTH LEAGUE, INC.

1712 Magnavox Way P.O. Box 2338

Fort Wayne, Indiana 46801

MEDICAL CLAIM FORM

1-800-237-2917 Fax 1-260-459-5910

NOTE: CLAIM FORM WILL BE RETURNED IF NOT FULLY COMPLETED

CA #0334819

AND SIGNED BY THE AUTHORIZED LEAGUE OFFICIAL.

on behalf of Nationwide Life Insurance Company

HOW TO FILE YOUR CLAIM

TO THE PARENT/GUARDIAN:

If you have an appointment with a doctor as the result of an

1. Part I is to be completed, signed and dated by the claimant

injury, please show this document to the doctor's insurance

or parent/guardian of claimant, if claimant is a minor.

secretary. You should be identified as a member of the

2. Attach itemized physician, hospital or other provider’s bills

following preferred provider networks and/or their affiliates.

for accident medical expenses being claimed. These bills

must show the patient’s name, condition being treated (diag-

Dear Doctor or Provider: This document indicates that this

nosis), type of treatment given, date the expense was

patient is a participant in the following preferred provider

incurred and the charges made.

networks and/or their affiliates:

TO THE LEAGUE:

1. Part II must be fully completed and signed by the League

Official.

2. Make copies of the claim form after it is completed and

signed by the league official and patient or parent/guardian.

3. The authorized league official should mail the completed

claim form and make note of date mailed to:

K&K Insurance Group, Inc.

Claims Department

P.O. Box 2338

Fort Wayne, IN 46801

NOTE: There is a $100.00 per person deductible.

Plan pays for covered medical expenses which occur within

52 weeks from the date of the injury.

PART I – TO BE COMPLETED CLAIMANT – OR PARENT/GUARDIAN IF CLAIMANT IS A MINOR

Plan pays for covered medical expenses which occur within 52 weeks from the date of the injury.

There is a $100 per person deductible.

PRINT Names of parent or guardian

(or claimant if not a minor): _______________________________________________________ Phone:____________________________

PRINT Address of Parent or Guardian

(or claimant if not a minor):________________________________________________________________________________________

Mailing Address

City

State

Zip

MEDICAL INFORMATION AUTHORIZATION

I hereby authorize the release of any and all medical information

A photostat of this authorization shall be considered as effective

required to process this claim.

and valid as the original.

I authorize any licensed physician, health care practitioner, hospi-

Patients or parent/guardian’s

Signature :____________________________________________

tal, clinic, medical or medically-related facility, insurance or reinsur-

ing company, insurance support organization, consumer reporting

Date:________________________________________________

agency, employer, or any other person or organization having

information available as to diagnosis, treatment, and prognosis

Any person who knowingly and with intent to injure, defraud or

with respect to any physical or mental condition and/or drug, alco-

deceive any insurance company or other person files a statement or

hol or psychiatric treatment and any other non-medical information

claim containing any materially false information or conceals for the

purpose of misleading information concerning any fact material

to give to K&K Insurance Group, Inc., or its legal representative,

thereto commits a fraudulent insurance act, which is a crime.

any and all such information.

➞

1309 1/07

OVER

Accident Proof Of Loss Claim Form - Babe Ruth League, Inc.

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