Chartis Medical/dental Insurance Claim Form printable pdf download

Chartis Medical/dental Insurance Claim Form

MEDICAL/DENTAL

INSURANCE CLAIM FORM

TO BE FILLED OUT BY MEDICAL PROVIDER AT THE TIME OF VISIT:

Student ID Number _________________________

Insurance Certificate #: 4.083.739 - Nacel Open Door

(from Insurance Card)

Name of Student:

Name of Host Family:

Street Address:

City:

State & Zip:

Email Address:

Phone number  Home  Cell  Work

Facility Information:  Hospital ER

 Physician/Medical Clinic

 Dental Office

 Hospital Stay

Name of Facility:

Name of Provider:

Street Address:

City:

State & Zip:

Phone Number:

Reason for Claim:  Illness  Accident  Dental

Date of Injury/Accident or Onset of Illness: ____________

Short description of injury, accident, or illness:

PROVIDERS:

To expedite claim payment, please complete this form and attach medical records, progress notes, or any supporting

documentation along with this form to:

Send with 1500 Health Insurance Claim Form; UB-04/UB-92; or ADA Claim Form.

All preventative services excluded from coverage and should be paid at the time of service (i.e. physicals,

immunizations, dental cleanings and exams).

Mail invoice and completed claim form to:

Nacel Open Door, Inc

Attn: Student Insurance

380 Jackson Street, Suite 200

St. Paul, MN 55101

P: 651-686-0080 x608 | F: 651-686-9601

L:Docs2006-12 Master DocumentsInsuranceNOD Chartis InsuranceWord Versions for Corrections” NOD Claim Form -updated 01-2013”

Last updated 2.23.2015

Chartis Medical/dental Insurance Claim Form