Form 892 - Claim For Hospital And Other Medical Expenses Template

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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.

Click here to clear form

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

4. Sex

Month

Day

Year

Self

Spouse/DP

Child

Dependent Parent

5. If claim is for son/daughter, was a Dependency (Tax Equivalency) Allowance payable at the time the expense was incurred?

Yes

No. If No, please answer questions A and B below.

A. Is he/she married?

Yes

No B. If over 18, is he/she a full time student & dependent upon you for support & maintenance?

Yes

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

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?

Yes

12. Is patient, other than

If Yes, Employee name?

13. Name and Address of Employer in Item 12.

Yes

staff member, employed?

14. Is patient covered by another group, student, government (e.g. Medicare) or employment related Medical Plan?

Yes

No, If Yes, enter:

Medical Plan Name

Group No.

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;

Date

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

Date

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?

Yes

No. If Yes, enter brief description and dates

16. Mailing Address (Street, City, State, ZIP)