MEDICAL CLAIM FORM
1. COMPLETE THIS FORM FIRST ADMINISTRATORS, INC.
2. ATTACH ALL BILLS CLAIM DEPT.
3. MAIL TO ►►►►►► PO BOX 9900
SIOUX CITY, IA 51102-0479
PHONE: (800) 206-0827
MUST ALWAYS BE COMPLETED BY EMPLOYEE
EMPLOYEE NAME ALTERNATE ID NUMBER EMPLOYEE BIRTH DATE
HOME ADDRESS EMPLOYEE DAYTIME PHONE
CITY STATE ZIP CODE NAME OF EMPLOYER OR GROUP # ACTIVE
PATIENT NAME (IF OTHER THAN EMPLOYEE) MALE PATIENT RELATIONSHIP TO EMPLOYEE PATIENT BIRTH DATE IS PATIENT:
MARRIED SINGLE DIVORCED
FEMALE LEGALLY SEPARATED
IS PATIENT FULL-TIME STUDENT? # OF CREDIT HOURS NAME OF SCHOOL
ACCIDENT: PLEASE PROVIDE DETAILS
DATE OF ACCIDENT IS THIS A CAR ACCIDENT? HOW AND WHERE DID ACCIDENT HAPPEN? TREATED
YES NO PREVIOUSLY?
DID ACCIDENT HAPPEN AT WORK? YES
YES NO NO
ILLNESS: PLEASE PROVIDE DETAILS
DATE ILLNESS BEGAN NATURE OF ILLNESS TREATED PREVIOUSLY?
IF YES, LIST: PHYSICIAN NAME PHYSICIAN ADDRESS DATE SEEN
IF YOU, THE PATIENT, OR SPOUSE HAS COVERAGE UNDER ANY OTHER GROUP HEALTH PLAN, HEALTH MAINTENANCE ORGANIZATION,
GOVERNMENT PLAN, OR INSURANCE POLICY WHICH ALSO PAYS FOR ANY OF THE EXPENSES OF THIS CLAIM, PROVIDE DETAILS.
NAME OF COVERED PERSON RELATIONSHIP COVERAGE: SINGLE FAMILY
NAME OF EMPLOYER OR GROUP, ETC. PROVIDING PLAN
NAME, ADDRESS AND PHONE NUMBER OF INSURANCE COMPANY
IS PATIENT ELIGIBLE FOR MEDICARE: YES NO IF YES: PART A PART B PART D EFFECTIVE DATE:
TYPE OF COVERAGE: MEDICAL DENTAL VISION MEDICAID VA IHS MEDICARE NUMBER: EFFECTIVE DATE: ________________________
QUALIFYING EVENT FOR MEDICARE? AGE ESRD DISABILITY MEDICARE DISABILITY? YES NO IF YES, EFFECTIVE DATE:
EMPLOYEE, PATIENT OR PARENT MUST SIGN BELOW
PAYMENT DIRECTION: AUTHORIZATION TO RELASEASE INFORMATION:
I agree that payment may be made directly to the provider of medical services. YES NO I hereby authorize any insurance company, payment organization, employer, hospital, or
(If payment option is not indicated, payment will be made to the medical care provider unless proof of physician to release all information with respect to myself or any of my dependents which may
payment is attached to this claim.) I understand that I am financially responsible for any charges not have a bearing on the benefits payable under this or any other plan providing benefits or
covered by this Benefit Plan. services. I hereby certify the information provided is correct and true to the best of my
X______________________________________________ ________________________ X__________________________________________ ____________________
Employee, Patient or Parent (if minor) Date Employee, Patient or Parent (if minor) Date
ADDITIONAL INFORMATION: (use an attached sheet if needed)
PROCEDURE FOR FILING A CLAIM
1. A separate claim form should be completed for each claimant on whom claims are being submitted.
A. Make sure you identify your employer or group.
B. If the patient is your dependent, be sure to complete all questions, including if married and if a full-time student.
C. It is important to know when, how and where your accident, illness or disability began, especially if it is job or auto related.
D. Questions regarding other coverage you or your dependent(s) are eligible for must be answered.
E. “If payment is not to be made to provider” – you should note accordingly and sign that section.
F. Patient or parent (if patient is a minor) must always sign the “Authorization to Release Information” section.
2. Attach all medical bills relating to claim.
A. Make sure all bills identify patient.
B. All bills should show date of treatment, type of service and amount of charges.
C. Prescription drug bills should be on regular receipts, showing name and address of pharmacy, name of patient, date of purchase, NDC number, name of medication and charge.
3. If you have other coverage that is primary (including Medicare or CHAMPUS), make sure you attach a copy of their explanation of benefits and itemized bill.