Geha International Claim Form
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1INTERNATIONAL CLAIM FORM
You may use the GEHA International Claim Form to submit institutional and professional claims for benefits for services received outside the
United States. Please include the Provider’s itemized bill(s) with this form.
Name of Subscriber:
GEHA ID Number:
Name of Patient:
Patient’s date of birth:
Were these expenses the result of an accidental injury? Yes
No
If “Yes,” please supply us with the following information: Accident date: ________________________
Time of accident: ____________________
Nature of accident: ___________________________________________________________________________________________________________
Type of
Date of
Provider name
provider
Description
Rate of
service
and address
(hosp., etc.)
of service
exchange
Charge
Diagnosis
Authorization for assignment of benefits – Complete if you prefer that benefits be paid directly to the Provider of service.
I, the undersigned, authorize and request GEHA to make payment for benefits due herein to:
Name of Provider: __________________________________________________________________________________________________
Signature of Subscriber/Patient: ____________________________________________________ Date: ______________________________
Government Employees Health Association, Inc.
Foreign Claims Department
P.O. Box 4665 • Independence, MO 64051-4665 • Telephone: (800) 821-6136 • Email:
• Website:
20120108
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