Get the free PEBTF Claim form - pebtf

Medical Reimbursement Plan Claim Form Pre-7/1/04 Non-Medicare Eligible HMO Members Member Information Before completing this form, please read the information on the reverse side. Member s Name Social

How to fill out pebtf claim form

How to fill out PEBTF claim form:

1. Start by obtaining a copy of the PEBTF claim form. It can usually be downloaded from the PEBTF website or requested from your employer's HR department.
2. Carefully read the instructions provided on the form. This will help you understand the information you need to provide and any specific requirements.
3. Begin by filling in your personal information, such as your name, address, phone number, and social security number. Make sure to provide accurate and up-to-date information.
4. Next, indicate the type of claim you are submitting. This could be for medical services, prescription drugs, or dental care, among others. Check the appropriate box and provide any additional details requested.
5. If you are filing a claim for medical services, you will need to provide information about the provider, including their name, address, and contact information. Include the date of service, a description of the service rendered, and the amount charged.
6. If you are submitting a claim for prescription drugs, include the name of the medication, the date it was prescribed, and the pharmacy where it was filled. Provide the cost of the medication and any co-pays or deductibles.
7. If you have incurred any out-of-pocket expenses, such as deductibles or co-pays, make sure to indicate the amount paid and provide any required documentation, such as receipts or explanation of benefits.
8. Review the completed form for any errors or missing information. Ensure that all required fields have been filled in correctly.
9. Sign and date the form to certify the accuracy of the information provided.
10. Keep a copy of the completed claim form and any supporting documentation for your records.

Who needs a PEBTF claim form?

1. Employees who are covered under the Pennsylvania Employees Benefit Trust Fund (PEBTF) healthcare plan may need to fill out a PEBTF claim form.
2. Retirees who receive healthcare benefits through the PEBTF may also be required to complete this form.
3. Any eligible dependents who have obtained medical, dental, or prescription services and require reimbursement or payment through the PEBTF will need to fill out the claim form as well.

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