Fill in Part I on screen, then print; or, print blank form & fill in
THE WORLD BANK GROUP
CLAIM FOR HOSPITAL AND OTHER MEDICAL EXPENSES
If illness or injury occured while at work, contact the Workers Compensation Insurance Representative, ext. 30807, BEFORE filling out this form.
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PART I - TO BE COMPLETED BY STAFF MEMBER OR RETIRED STAFF MEMBER (hereinafter: staff member) OR PATIENT IF COVERED SEPARATE FROM STAFF MEMBER
1. Patient's Name (Last, First, M.I.)
2. Patient's Relationship to Staff Member
3. Patient's Birthdate
5. If claim is for son/daughter, was a Dependency (Tax Equivalency) Allowance payable at the time the expense was incurred?
No. If No, please answer questions A and B below.
A. Is he/she married?
No B. If over 18, is he/she a full time student & dependent upon you for support & maintenance?
6. Staff Member's (or Surviving Spouse's) Name (Last, First, M.I.)
7. Staff Member's (or Surviving Spouse's) Birthdate
8. UPI No.
IF NOT PATIENT
IF NOT PATIENT
9. Nature of illness, injury or service
10. If claim is for accidental injury, enter date and indicate where and how it occurred
11. Is claim for second surgical opinion?
12. Is patient, other than
If Yes, Employee name?
13. Name and Address of Employer in Item 12.
staff member, employed?
14. Is patient covered by another group, student, government (e.g. Medicare) or employment related Medical Plan?
No, If Yes, enter:
Medical Plan Name
Name & Address of Carrier
I authorize the release to the World Bank Group Medical Insurance Plan administrator, to the World Bank Group or their representative, any information including medical,
employment and benefit information required for claim processing or plan administration. Such information shall be released directly to the World Bank Group only in
circumstances where fraud or misconduct is believed to have occurred. This authorization to release information is valid for two years after the date signed. A copy of this
authorization shall be as valid as the original. If the staff member is incapacitated or deceased, the Personal Representative or next of kin must sign.
Patient's Signature (Parent/Guardian, if minor;
leave blank if staff member)
I certify that the statements here and attached are complete and accurate. As the patient, I authorize the release of information as described above.
Staff Member's Signature
PART II - TO BE COMPLETED BY ATTENDING PHYSICIAN (in lieu of itemized bill)
15. Physician's Name
17. Is treatment result of occupational illness or injury?
No. If Yes, enter brief description and dates
16. Mailing Address (Street, City, State, ZIP)
18. Date symptoms first appeared or accident happened?
19. Physician's S.S.N. or T.I.N.
20. Physician's License No.
21. Physician's Telephone No.
22. Date you were first consulted on this condition?
23. Diagnosis and current condition
24. Has patient ever had same or similar condition?
No, If Yes, indicate when and describe
25. Is patient still under your care for this condition?
Date of Service
26. I certify that the procedures as
indicated by date have been completed
Return completed form to:
Aetna/World Bank MIP Claims P.O. Box 14199 Lexington, KY 40512-4199 USA OR via internal mail to MIP claims MSN MC-C3-309.
Keep a copy of completed form for your records