Harvard Pilgrim Health Care Claim Form
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1
2Harvard Pilgrim Health Care
P.O. Box 699183
Quincy, MA 02269
CLAIM FORM
1-888-333-4742
TO THE MEMBER
1.
Please read and complete this side of the claim form.
2.
Please ask your provider to read and complete the back side of the claim form or they may
attach a complete and itemized bill.
3.
PLEASE SIGN ONLY ONE OF THE “ASSIGNMENT OF BENEFITS” BOXES.
4.
In states other than Massachusetts and Maine, Allianz Life is the Underwriter of out-of-net-
work benefits for fully insured accounts.
SUBSCRIBER NAME
FIRST
INITIAL
LAST
ADDRESS (STREET AND NO.)
CITY
STATE
ZIP
PATIENT’S NAME
FIRST
INITIAL
LAST
MEMBER IDENTIFICATION NO. (FROM I.D. CARD)
DATE OF BIRTH
SEX
M o
___ ___ ___ ___ ___ ___ ___ ___ ___ – ___ ___
/
/
F o
IS THE CONDITION REQUIRING
o YES
o YES
AUTO ACCIDENT
INJURY
o YES
o NO
o NO
TREATMENT RELATED TO:
EMPLOYMENT
o NO
DATE OF ILLNESS
MONTH
DAY
YEAR
HOW AND WHERE DID ACCIDENT OCCUR?
OR ACCIDENT
/
/
o YES
IS THE SUBSCRIBER’S
IF YES, NAME OF COMPANY
o NO
SPOUSE EMPLOYED?
o YES
IS PATIENT COVERED BY
IF YES, NAME OF OTHER INSURANCE
ID NUMBER
o NO
OTHER HEALTH INSURANCE?
o YES
IS PATIENT COVERED BY
IF YES, NAME OF OTHER INSURANCE
ID NUMBER
o NO
OTHER DENTAL INSURANCE?
I hereby apply for benefits and certify that the above information is complete, true and correct. To all physicians and other medical
professionals, hospitals, and other medical care institutions, and to insurers, medical or hospital service and prepaid health plans,
employers and group policy holders, contract holders or benefit plan administrators: You are authorized to provide the Plan and any
benefit plan administrators from consumer reporting agencies, attorneys and independent claim administrators acting on the Plan’s
behalf, with information concerning medical care, advice, treatment or supplies provided to the Patient, and any employment related
information regarding the Patient. This information will be used for the purpose of evaluating and administering claims for benefits.
I understand that the duration of the authorization is for the term of coverage of the policy or contract under which a claim for health
benefits has been submitted. I understand that I have a right to receive a copy of this authorization upon request. I agree that a
photographic copy of this authorization is as valid as the original.
CLAIM CANNOT BE PROCESSED WITHOUT MEMBER’S SIGNATURE.
SUBSCRIBER’S SIGNATURE
DATE
DEPENDENT PATIENT’S SIGNATURE
DATE
IF NOT A MINOR
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