Afs-Usa, Inc. Medical Claim Form
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1
2AFS-USA, Inc.
Medical Claim Form
SUBMIT CLAIM FORM TO:
PLEASE READ THIS IMPORTANT INFORMATION
• Healthcare providers submitting claims directly to GMMI do not have to complete this form.
• Host family or participant should complete this form if requesting reimbursement for bills already
Global Medical Management, Inc. (GMMI)
paid by them. If you are given a copy of the industry standard HCFA-1500 or UB-92 Form by
1300 Concord Terrace, Suite 300
the healthcare provider, attach it to this form. If you do so, there is no need to complete the
Sunrise, FL 33323
“physician or supplier” section on the back page of this form.
Phone: (888) 444-7773
• Reimbursement requests for prescription medications must be accompanied by the original
Fax:
(954) 370-8130
prescription receipt. The prescription receipt is the tag/label that comes attached to the
e-mail:
medication containing the student name, doctor/medicine/pharmacy name, date filled, cost, etc.
PARTICIPANT STATEMENT
_______________________________________________________________________________
___________________________________________________________________________
PARTICIPANT NAME (FIRST)
HOST FAMILY’S NAME
_______________________________________________________________
_________________________________________________________________
_____
(LAST)
STREET ADDRESS
____________________________________________________________________
_________________________________________________________________
PARTICIPANT ID#
DATE OF BIRTH (MM/DD/YYYY)
CITY
STATE
ZIP
_________________________________________________________________
____________________________________________________________________
HOST FAMILY’S PHONE NO. (WITH AREA CODE)
PARTICIPANT’S COUNTRY OF ORIGIN
PROGRAM START DATE (MONTH/YR.)
SERIOUS illness, injury or accident MUST be reported to your AFS Regional Service Center immediately by telephone (800-876-2377) with date when
accident/illness occurred, name, address and telephone numbers of attending physician and hospital/clinic. Serious cases are motor vehicle accidents,
hospitalizations, broken bones, etc. Please consult your HANDBOOK then complete this form and mail to GMMI.
MINOR illness or injury should be described fully on this form and mailed to GMMI on the same day illness or injury occurred.
Is this illness related to any condition existing prior to arrival in the US?
Yes
No
PHYSICIAN
HOSPITAL/CLINIC
_
_________________________________________________________
__________________________________________________________
NAME
NAME
_________________________________________________________________
____________________________________________________________________
ADDRESS
ADDRESS
_________________________________________________________________
____________________________________________________________________
CITY
STATE
ZIP
CITY
STATE
ZIP
_________________________________________________________________
____________________________________________________________________
(AREA CODE) TELEPHONE NUMBER
(AREA CODE) TELEPHONE NUMBER
_______________________________________________
_____________________________________________
_________________________________________
DATE OF ILLNESS
THIS DATE
PROVIDER’S TAX ID#
___________________________________________________________________________________________________________________________________________________________________________
ATTENDING PHYSICIAN (IF DIFFERENT FROM ABOVE)
(AREA CODE) TELEPHONE NUMBER
___________________________________________________________________________________________________________________________________________________________________________
ADDRESS
CITY
STATE
ZIP
PAYMENT OF MEDICAL BILL
Is the participant covered by a school or other insurance?
Yes
No
(If yes, give name and address)
___________________________________________________________________________________________________________________________________________________________________________
INSURANCE NAME
(AREA CODE) TELEPHONE NUMBER
___________________________________________________________________________________________________________________________________________________________________________
ADDRESS
CITY
STATE
ZIP
PLEASE CHECK:
No bill expected
Bill (s) will be forwarded
Bill(s) enclosed and should be paid directly
Paid bills with cancelled check(s) and/or receipt enclosed
PERSON TO BE REIMBURSED - All reimbursement checks payable to
participants are issued in US currency and made out to the participant’s name
I certify that the preceding statements and answers, and the
c/o U.S. host family address
.
attached bills and/or statements are true and complete to the
_
__________________________________________________________
best of my knowledge. I authorize the release of information
PARTICIPANT NAME
and medical records to Global Medical Management Inc.
containing the diagnosis and treatment provided to me. I
____________________________________________________________________
ADDRESS
understand that this information will be held confidential.
____________________________________________________________________
___________________________________________________
CITY
STATE
ZIP
Signature
Date (mm/dd/yyyy)
____________________________________________________________________
(OVER)
(AREA CODE) TELEPHONE
Jan15/09
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