Critical Condition Coverage Claim Report Form
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1
2ADA MedCASH PLAN
P.O. BOX 17410
DENVER, CO 80217-0410
1-866-257-0707 - Tel
1-303-737-2879 - Fax
CRITICAL CONDITION COVERAGE CLAIM REPORT
MEMBER'S STATEMENT - PLAN 1107
1. Name:_________________________________________
2. ADA Association # ______________________________________
3. Date of Birth:________/________/________
4. Sex:
Male
Female
5. Home Address (No., Street, City, State, Zip): ____________________________________________________________________
________________________________________________________________________________________________________
6. Home Phone Number: (______) _____________________ 7. Office Phone Number: (______) __________________________
8. Have you ever filed/submitted a claim for Critical Condition Coverage?
Yes
No
9. Have you ever received any medical treatment, care, advice or medication for the same or related condition?
Yes
No
10. For which Critical Condition Category are you claiming a benefit? (refer to pages 3-5 of your certificate): ______________________
________________________________________________________________________________________________________
11. Date Symptoms first occurred:________/________/________
12. Date of first medical consultation for Critical Condition being claimed:________/________/________
Name of Physician: ________________________________________________________________________________________
Address________________________________________________________________ Phone # (_____)____________________
13. Date of First Diagnosis:________/________/________ Name of Physician: ____________________________________________
Address________________________________________________________________ Phone # (_____)____________________
14. Is present condition due to an accident?
Yes
No
15. Describe how and where accident occurred. If motor vehicle accident, attach a copy of the police/accident report: ______________
________________________________________________________________________________________________________
16. Current Treating Physician’s Name:____________________________________________________________________________
Address________________________________________________________________ Phone # (_____)____________________
17. List hospitalizations (if applicable):
Names and Addresses of Hospitals
Dates of Confinement
__________________________________________________________________
_____/_____/_____ to _____/_____/_____
__________________________________________________________________
_____/_____/_____ to _____/_____/_____
18. List names and addresses of other treating Physicians and/or referrals (Please attach additional pages if necessary)
Names and Addresses of Physicians
Specialty
Phone #
Date of Last Visit
_______________________________________________ __________________ (____)______________ _____/_____/_____
_______________________________________________ __________________ (____)______________ _____/_____/_____
_______________________________________________ __________________ (____)______________ _____/_____/____
PLEASE SIGN AND DATE AUTHORIZATION ON BACK OF THIS PAGE
M4738 (Rev. 09/11)
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