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MEDICAL/SURGICAL CLAIM FORM SEND COMPLETED CLAIM FORM TO: UNITE HERE HEALTH, P.O. 6525, Aurora, IL 605986525 FILING A CLAIM Please fill out this form completely 1. Network hospitals and doctors will

How to fill out medicalsurgical laim form

How to fill out a medicalsurgical claim form:

1. Gather all necessary information: Before filling out the form, gather all relevant information such as your personal details, insurance information, healthcare provider information, dates of service, and any supporting documentation or medical records.
2. Review the form: Take a few minutes to review the form thoroughly. Make sure you understand the sections and questions being asked. If anything is unclear, don't hesitate to seek assistance from your healthcare provider or insurance company.
3. Complete personal information: Start by entering your personal details accurately, including your name, address, phone number, date of birth, and social security number. These details are essential for proper identification and processing.
4. Provide insurance information: Next, provide your insurance information, including the name of your insurance company, policy number, group number, and any other relevant details. Double-check the accuracy of this information as errors could result in delayed or denied claims.
5. Fill in healthcare provider details: Enter the name, address, and contact information of the healthcare provider or facility where you received medical treatment. This may include the name of the hospital or clinic, the attending physician, and their identification numbers if applicable.
6. Provide dates of service: Indicate the specific dates when you received the medical treatment or underwent surgery. Be as precise as possible to ensure accurate processing of your claim.
7. Describe the medical procedure or treatment: In this section, provide a detailed description of the medical procedure or treatment you received. Include the diagnosis, CPT (Current Procedural Terminology) codes, ICD-10 (International Classification of Diseases, 10th Revision) codes, and any other pertinent information as requested by the form.
8. Attach supporting documentation: If required, attach any supporting documentation such as medical records, invoices, receipts, or explanation of benefits (EOB) forms to substantiate your claim. Make sure to include all pages of such documents and keep copies for your records.
9. Review and submit: Before submitting the form, carefully review all the information provided. Double-check for any errors or omissions that could potentially delay processing. Once you are satisfied with the accuracy, sign and date the form, and submit it to your insurance company following their preferred submission method (e.g., mail, online portal, email).

Who needs a medicalsurgical claim form?

The medicalsurgical claim form is typically required by individuals who have received medical treatment, undergone surgery, or had a healthcare service provided to them. It is necessary for individuals seeking reimbursement from their insurance company for the expenses incurred in these medical procedures. The form is relevant whether you have private health insurance, Medicare, or Medicaid, as it helps facilitate the claims process and ensure proper documentation of healthcare services rendered.

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