ASPCA U0314 - CS22 free printable template

Com scan and attach your receipts 1-866-888-2495 no cover sheet necessary Mail ASPCA Pet Health Insurance 1208 Massillon Rd. Suite G 200 Akron Ohio 44306 Please choose only one method. Duplicate claim submissions may delay processing. U0314 - CS22 Page 1 of 2 - You must submit an itemized invoice with this claim form. How do I use my plan Visit any licensed veterinarian in the U.S. or Canada including specialists and emergency clinics. I authorize United States Fire Insurance Company and its...business partners to review and obtain a copy of ALL RECORDS including the insurance claim records and medical records as to examination history diagnosis treatment and prognosis with respect to any condition. I further authorize these entities to disclose identifying information about me and my pet as well as information about my claim experience to my veterinarian. Signature of Pet Owner Date Please read IMPORTANT NOTICE document that follows for additional information. 4 3 Easy Ways to Submit...a Claim Form- You must submit an itemized invoice with this claim form. E-Mail claims aspcapetinsurance. com scan and attach your receipts 1-866-888-2495 no cover sheet necessary Mail ASPCA Pet Health Insurance 1208 Massillon Rd. For office use only HAVE A QUESTION Call us at 1-866-204-6764 Claim Form PLEASE INCLUDE YOUR PET S MEDICAL RECORDS TO HELP EXPEDITE PROCESSING* 1 General Information Your Information Please fill out this form completely. Incomplete forms will delay processing* Pet...Information Check here if this is a new address Name Account Number Address City State Zip Breed Phone Email Age HELP US By providing the Story of Occurrence/Diagnosis you will help us avoid delays in processing your claim* 2 Diagnosis/Symptom Information Story of Occurrence/Diagnosis This claim is related to Gender - Please describe this incident including dates details and symptoms leading up to it. Accident Is this claim an estimate for future treatment Illness Yes Wellness Veterinarian No...Clinic Name Fax Total amount claimed Date illness/injury first occurred Did any other veterinarian treat your pet Send payment to Me Is this a new condition 3 Pet Owner Declaration I confirm to the best of my knowledge the above statements are true in every respect. I understand that the fees listed may not be covered or may exceed my plan benefit. I understand that I am financially responsible to my veterinarian for the entire treatment. I understand that this claim cannot be adjusted without...itemized receipts. I also understand that the deliberate misrepresentation of the animal s condition or the omission of any material facts may result in the denial of the claim and/or the cancellation of coverage. I authorize United States Fire Insurance Company and its business partners to review and obtain a copy of ALL RECORDS including the insurance claim records and medical records as to examination history diagnosis treatment and prognosis with respect to any condition* I further authorize...these entities to disclose identifying information about me and my pet as well as information about my claim experience to my veterinarian* Signature of Pet Owner Date Please read IMPORTANT NOTICE document that follows for additional information* 4 3 Easy Ways to Submit a Claim Form- You must submit an itemized invoice with this claim form* E-Mail claims aspcapetinsurance.