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0217Health Benefits Trust Fund Cost Plus Claim Form Incomplete forms will be returned. Please refer to the Guide to Submitting Cost Plus Claims before submitting your claim. Print clearly, in ink.

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How to fill out paper claim form preparation

01

Start by carefully reading the instructions provided with the paper claim form.

02

Collect all the necessary documents and information that will be required to fill out the form, such as medical records, invoices, and receipts.

03

Begin filling out the form by entering your personal information, including your name, address, and contact details.

04

Provide the necessary details about the healthcare provider or facility you received the services from, such as their name, address, and contact information.

05

Fill in the details of the services you received, including the date of service, the diagnosis or reason for the service, and any codes or references provided by the healthcare provider.

06

Attach copies of all the necessary supporting documents, making sure they are legible and properly organized.

07

Review the completed form for accuracy and completeness, making any necessary corrections or additions.

08

Once you are satisfied with the form, sign and date it as required.

09

Make a copy of the completed form and all supporting documents for your records.

10

Finally, submit the form and supporting documents to the appropriate party as instructed in the claim form's guidelines.

Who needs paper claim form preparation?

01

Anyone who wishes to submit a claim for reimbursement or payment related to healthcare services may need to fill out a paper claim form. This includes individuals who are not covered by insurance or those whose insurance provider requires paper submissions.

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