Health Screening Benefit Claim Filing Instructions Page 2
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1
2California
County of Stanislaus Group #7210391000
Includes:
$100 Health Screening Benefit
$200 Mammography Screening Benefit
Critical Illness and Supplemental Health – Health Screening Benefit Claim Form
This claim form can be used to request reimbursement for your Health Screening Benefits under your Critical Illness plan.
You can either have your physician complete and sign the information below or attach documentation from the provider indicating the date of
service, and the service provided (description or CPT code).
Submission of the Health Screening benefit claim form is not a guarantee of payment. Plan requirements do vary and coverage will be based on
your policy provisions. Additional information may be required. Most Critical Illness plans require services be provided more than 90 days after
the effective date in order to be eligible for coverage. However, these limitations can vary per plan. Review your plan for more
information on the specific information on the wellness/health screening benefits and applicable claims waiting periods.
Section I – Member Information:
Policyholder
Dependent
Is the claim for the:
Policyholder’s Name ____________________________________________________________
Policy No. ___________________
Street Address________________________________________________________________
Social Security No. ____________
City ____________________________________
State ________
ZIP Code __________
Date of Birth ____ /____/______
Daytime Telephone No. (______)__________________
Claimant Name _______________________________________________________________
Date of Birth ____ /____/______
Section II – Provider Information
:
Printed Name of Physician ________________________________________________________
Phone No. (_____) ____________
Street Address__________________________________________________________________
Specialty ____________________
City ____________________________________
State ________
ZIP Code __________
Signature of Physician________________________________________________________________
Date ______ /______/________
:
Section III – Service Information
Please check all services provided below:
Bone Marrow testing
CA 15-A (for Breast Cancer
CA-125 (Ovarian Cancer)
Chest X-ray
CEA (Colon Cancer)
Colonoscopy
Flexible Sigmoidoscopy
Hemocult Stool Analysis
Mammography (including ultrasound)
Pap Smear
PSA (Prostate Cancer)
Serum Protein Electrophoresis
Biopsy for Skin Cancer
Stress Test (bike or treadmill)
Electrocardiogram (EKG)
Lipid Plan
Blood test for Triglycerides
Oral Cancer Screening using ViziLite, OraTest
or other current dental code D0431
Any Person, who with the intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an Application or files a claim
containing a false or deceptive statement may be subject to prosecution and punishment for insurance fraud. (See State Specific Fraud Warning
Statements on page 3)
The above statements are true to the best of my knowledge and belief.
________________________________________________________ ____ /____/______
Signature of Policyholder
Date
GNHH5LZHH 10/11
Mail to:
Humana/Kanawha Insurance Company
Customer Service:
1-877-378-1505
PO Box 2000
Fax Number:
1-502-405-7107
Email:
Lancaster, SC 29721-2000
Page 2
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