This form is designed to provide a comprehensive structure for submitting a medical claim for reimbursement to an insurance company. Please fill out all sections completely to avoid delays in processing.
First Name
Last Name
Policy Holder ID/Employee ID
Policy/Group Number
Date of Birth
Contact Phone Number
Email Address
Street Address
Street Address Line 2
City
State/Province
Postal/Zip Code
If the patient is the Policy Holder, check here and proceed to Section 3.
Patient Full Name
Patient Date of Birth
Patient Relationship to Policy Holder
Patient ID (if applicable)
Date of Service (First)
Date of Service (Last)
Type of Claim
Illness
Injury
Maternity
Wellness
Other:
Brief Description of Illness/Injury/Reason for Visit.
Provider/Facility Name
Provider/Facility Tax/Identification Number
Contact Phone Number
Street Address
Street Address Line 2
City
State/Province
Postal/Zip Code
Attending Physician Name
Physician Specialty
Date of Service | Description of Service/CPT Code | Amount Billed | Amount Paid by Patient | ||
|---|---|---|---|---|---|
A | B | C | D | ||
1 | |||||
2 | |||||
3 | |||||
4 | |||||
5 | |||||
6 | |||||
7 | |||||
8 | |||||
9 | |||||
10 | |||||
11 | TOTAL CLAIM AMOUNT (Sum of 'Amount Billed') | $0.00 |
Please attach all original, itemized bills, receipts, and physician notes.
File Name | Upload File | ||
|---|---|---|---|
A | B | ||
1 | |||
2 | |||
3 | |||
4 | |||
5 |
Do you have other insurance coverage for these services?
If Yes, please complete the following:
Other Insurance Company Name
Policy/Group Number
Name of Insured on Other Policy
Amount Paid by Other Insurer
Attach Explanation of Benefits - EOB
Please select how you would like to receive your reimbursement:
Option 1:
Check/Bank Draft
Send to Policy Holder's Mailing Address (Section 1)
Option 2:
Direct Deposit/Electronic Funds Transfer (EFT)
Bank Name
Account Number
Routing/Sort Code
I certify that the information provided in this claim form is true, accurate, and complete.
I authorize any healthcare provider, facility, or other insurer to release necessary medical information to the insurance company or its authorized agents for the purpose of processing this claim.
I understand that the intentional misrepresentation of facts may result in the denial of this claim and/or further action.
Please ensure you have attached the following before submitting this form:
Original, itemized bills/invoices from the provider/facility.
Proof of payment (receipts, bank statements, etc.).
Physician's notes, report, or prescription (as required by your policy).
Explanation of Benefits (EOB) from any other insurance company (if applicable).
To configure an element, select it on the form.