Medical Claim Form (Medical/dental/vision) printable pdf download

Send claims to:

Healthcare Management Administrators

P.O. Box 85008, Bellevue, WA 98015

Toll Free (800) 869-7093 Local (425) 462-1000

MEDICAL CLAIM FORM (Medical/Dental/Vision)

PART 1: Employee Information

EMPLOYEE NAME (Last and First)

EMPLOYEE DATE OF BIRTH

EMPLOYEE SOCIAL SECURITY #

GROUP #

MONTH

DAY

YEAR

020256

EMPLOYEE ADDRESS

CITY

STATE

ZIP

IS THIS AN ADDRESS

EMPLOYEE'S TELEPHONE NUMBER

CHANGE?

YES

MARITAL STATUS

SINGLE

MARRIED______________________________________

WIDOWED

LEGALLY SEPARATED

DIVORCED

NAME OF SPOUSE

YES

IF DIVORCED & CLAIM IS FOR DEPENDENT CHILD, ANSWER THE FOLLOWING QUESTIONS: A) IS THIS CHILD IN YOUR PERMANENT CUSTODY?

YES

B) IS THERE A COURT ORDER FOR PROVISION OF MEDICAL CARE FOR THIS CHILD?

PART 2: Patient Information

PATIENT NAME

EMPLOYEE

SPOUSE

CHILD

OTHER

IS PATIENT

IF OTHER, SPECIFY____________________________

PATIENT'S DATE OF BIRTH

IF CLAIM IS FOR DEPENDENT OVER AGE 19, IS THE DEPENDENT A FULL TIME STUDENT?

MONTH

DATE

YEAR

IF SO, PLEASE PROVIDE PROOF OF STUDENT STATUS.

PART 3: Description of Claim

DESCRIBE ILLNESS OR INJURY:

WORK RELATED ILLNESS OR INJURY?

IF CLAIM IS DUE TO ACCIDENT STATE WHEN, WHERE AND

HOW THE ACCIDENT OCCURRED:

YES

IF YES, DID YOU OR WILL YOU BE FILING A CLAIM WITH L&I?

YES

HAS PATIENT BEEN TREATED FOR THIS ILLNESS OR INJURY WITHIN THE PAST 12 MONTHS?

IF YES, NAME AND ADDRESS OF ATTENDING PHYSICIAN

REFERRING PHYSICIAN IF APPLICABLE _______________________________________

YES

IF YES, DATE OF SERVICE: _________________

PART 4: Other Group Health Insurance

ARE YOU OR ANY OF YOUR FAMILY MEMBERS COVERED BY OTHER MEDICAL INSURANCE?

NAME AND ADDRESS OF OTHER INSURANCE CARRIER:

YES

CHECK ONLY THOSE COVERED BY OTHER GROUP INSURANCE.

SELF

SPOUSE

_________

DEPENDENT(S)

DATE OF BIRTH

LIST THE DEPS. _______________________________________

POLICY NUMBER: _________________________

_______________________________________

EFFECTIVE DATE: __________________________

_______________________________________

IS PATIENT ELIGIBLE FOR MEDICARE BENEFITS?

YES

IF YES, ENTER DATE OF ELIGIBILITY _____________________

SOCIAL SECURITY NO.______________________________

PART 5: Complete for all claims

I HEREBY CERTIFY THAT THE ABOVE STATEMENTS ARE COMPLETE AND ACCURATE TO THE BEST OF MY KNOWLEDGE

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURANCE COMPANY, FILES A STATEMENT OF CLAIM CONTAINING FALSE INCOMPLETE OR

MISLEADING INFORMATION MAY BE GUILTY OF A CRIMINAL ACT PUNISHABLE UNDER LAW.

EMPLOYEE SIGNATURE _____________________________________________

DATE _________________________________

PART 6: Claims Benefit Assignment and Authorization

SIGNED (BY EMPLOYEE)

SIGN HERE IF YOU WISH PAYMENT TO BE MADE TO YOU, OTHERWISE IT WILL GO TO THE PROVIDER OF CARE., ______________________________________ DATE ____________________

AUTHORIZATION TO RELEASE INFORMATION: I expressly authorize any provider of care to furnish

SIGNED (BY PATIENT, OR PARENT, IF MINOR)

HMA , any records concerning me or any Member of my family for whom benefits or services has been

claimed.

_________________________________________________ DATE _____________________