Student Claim Form North Carolina printable pdf download

School District:

Wake County Public School System

Student Claim Form

City and State:

Raleigh, North Carolina

UnitedHealthcare StudentResources

P.O. Box 809027

School Name: ____________________________________________________

Dallas, TX 75380-9027

Policy Number:

08-1775

(888) 251-6160

Student’s

Last Name____________________________________

First Name____________________________

Nickname______________________

(If Applicable)

Date of Birth __________________________________

Grade _______________

Name of

Address

Parent/

Street/

Legal

PO Box

Guardian

City

State

Zip Code

WHAT OTHER INSURANCE COMPANY/COMPANIES PROVIDE COVERAGE THAT WOULD COVER THIS CLAIM?

Name of Company(s)_________________________________________________ Name of Insured ___________________________________________

If NO Other Insurance, Sign Here__________________________________________________

STATEMENT BELOW MUST BE SIGNED WHEN TREATMENT REQUIRES SURGERY OR HOSPITAL CONFINEMENT.

I hereby authorize the hospital or doctors involved to give UnitedHealthcare StudentResources all information regarding the insured’s condition,

including the history obtained, findings and diagnosis. A photocopy of this form shall be considered as valid as the original.

Date_______________________________Signature of Parent or Legal Guardian _________________________________________________________

I authorize payment directly to my medical provider(s) for charges for this claim. I understand that I am financially responsible for all charges not

covered by this authorization.

Date____________________________ Signature of Parent or Legal Guardian__________________________________________________________

DESCRIBE ACCIDENT/ILLNESS IN DETAIL

Date of Injury_____________________ Time of Injury ________________( ) AM ( ) PM

Date of First Treatment__________________

Place of Injury _______________________________________

Name of Person Supervising the Activity

__________________________________

Which Best Describes the Activity:

( ) P.E Class

( ) Athletic Period

( ) On School Property during

( ) During Lunch Hr

( ) School Sponsored Activity

during school hours

( ) Not School Related

( ) A Spectator

( ) Traveling to/from school

( ) In School Bus

( ) School Sponsored Field Trip

Describe how injury happened or the nature of an illness?___________________________________________________________________________

_____________________________________________________________________________________________________________________________

If engaged in an Interscholastic Sport at the time of the injury, what was the sport?______________________________________________________

REPORTS OF AT-SCHOOL OR ATHLETIC INJURIES MUST BE CERTIFIED BY A SCHOOL OFFICIAL

I hereby certify that the above named student was insured under the UnitedHealthcare StudentResources Plan at the time of the accident and I

believe the accident occurred as stated herein.

Date________________Parent or Legal Gardian________________________________________School Official________________________________

TO ASSURE TIMELY PROCESSING OF YOUR CLAIM, PLEASE VERIFY ALL THE QUESTIONS ABOVE ARE ANSWERED. ATTACH

ITEMIZED BILLS, PAID RECEIPTS, EXPLANATIONS OF BENEFITS, AND ALL RELEVANT DOCUMENTS TO THIS CLAIM FORM.

Student Claim Form North Carolina

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