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Telephone numbers Home Work 7. Patient s SSN 8. Date of Birth Mo/Day/Yr 9. Relationship to Insured 10. 5011 GATE PARKWAY BLDG. 200 JACKSONVILLE FLORIDA 32256 ATTN Group Claims Department To receive claims assistance please call 1-800-696-8562 HOSPITAL INDEMNITY CLAIM STATEMENT INSTRUCTIONS FOR THE INSURED 1. When an overpayment is made I authorize FCL to recover the excess from any person to which payment is made. Diagnosis and concurrent conditions include ICD Code s Date symptoms first...

How to fill out hospital indemnity claim statement

How to fill out hospital indemnity claim statement

1. Gather all necessary information such as policy number, insured person's details, and details of the hospital visit.
2. Start by section 1 of the claim statement, providing personal information like name, address, and contact details.
3. Move on to section 2 where you will enter the policy information, including the policy number and effective dates.
4. In section 3, specify the insured person's details such as name, date of birth, and relationship to the policyholder if applicable.
5. Proceed to section 4 and provide details of the hospital visit, including the date of admission and discharge, name of the hospital, and reason for the visit.
6. In section 5, list any other insurance coverage that may be applicable to the claim.
7. Section 6 is for attaching additional documentation such as medical bills, itemized statements, or any other supporting documents.
8. Review the entire claim statement to ensure all information is accurate and complete.
9. Sign and date the claim statement, certifying that all information provided is true and accurate.
10. Submit the completed claim statement along with any supporting documents to the designated claims department or insurance provider.

Who needs hospital indemnity claim statement?

1. Anyone who has purchased a hospital indemnity insurance policy and requires reimbursement for hospital-related expenses.
2. Policyholders who have undergone a hospital stay or incurred medical expenses that are covered under their hospital indemnity insurance policy.
3. Individuals who want to claim benefits for hospitalization, surgeries, emergency room visits, or other eligible medical services covered by their policy.
4. Those who want to receive financial coverage for the costs associated with hospital visits, such as room and board, diagnostic tests, surgeries, and other eligible expenses.

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What is hospital indemnity claim statement?

Hospital indemnity claim statement is a document that outlines the details of a claim made by an individual or their representative for reimbursement of hospital expenses.

Who is required to file hospital indemnity claim statement?

The individual who received medical treatment at a hospital and wishes to claim reimbursement for the expenses is required to file the hospital indemnity claim statement.

How to fill out hospital indemnity claim statement?

To fill out a hospital indemnity claim statement, the individual needs to provide their personal information, details of the hospital visit, description of services received, and any supporting documents such as medical bills.

What is the purpose of hospital indemnity claim statement?

The purpose of hospital indemnity claim statement is to request reimbursement for medical expenses incurred during a hospital visit.

What information must be reported on hospital indemnity claim statement?

The hospital indemnity claim statement must include the individual's name, contact information, insurance policy details, hospital name, dates of service, description of services received, and total amount of expenses incurred.