How to file a long-term care insurance claim by lhh12385

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									                                                                                                        tel 800.362.0700
                                                                                                        fax 610.965.6962
                                                                                                        www.penntreaty.com




                                  How to file a long-term care insurance claim

            Step 1

            Complete all questions and sign this form. Review the form before mailing to ensure:
            • All questions are completed
            • The policy number(s) is correct
            • The form is signed by you, the claimant, or your legal representative
            • If your representative has signed the form, enclose a copy of the legal document authorizing your
              representative to act on your behalf


            Step 2

            Attach any itemized bills. Make sure that each itemized bill shows the following:
            • Full name of claimant
            • Date each service was received
            • Type of service
            • Amount charged for each service
            • Name and address of the provider of service


            Step 3

            Mail all forms, itemized bills, and legal documents to:
            Claims Department, P.O. Box 7066, Allentown PA 18105-7066




                                            Penn Treaty Network America Insurance Company
                                   (Penn Treaty Network America Life Insurance Company in California)
                                                 American Network Insurance Company

                                ATTN Claims Department :: PO Box 7066 :: Allentown, PA 18105-7066
CIF 06/08
                                                                                                          tel 800.362.0700
                                                                                                          fax 610.965.6962
                                                                                                          www.penntreaty.com


                                    CLAIMANT’S INFORMATION FORM
1. Claimant name _______________________________________________ Policy # ________________________
2. Telephone: Day ( _____ ) _________________ Eve ( _____ ) _______________ 3. DOB _____ /_____ /_____
4. Address where correspondence, bills, and claim checks are to be sent:
    Street ____________________________________________________________________________________________
    City________________________________________________________ State___________ Zip__________________
5. Describe injury or sickness _______________________________ 6. Date of first symptoms _____ /_____ /_____
7. Attending physician ___________________________________________ Telephone ( ______ ) ________________
    Street _____________________________________________________________________________________________
    City________________________________________________________ State________________ Zip______________
8. Were you recently discharged from a hospital?               yes        no            If yes, complete the following:
    Date admitted _____ /_____ /_____            Date discharged _____ /_____ /_____
    Hospital name _____________________________________________________________________________________
    Street _____________________________________________________________________________________________
    City_______________________________________________________ State__________ Zip____________________
9. For which benefit type are you requesting benefits?
       facility care   adult day care        respite care            home health           other __________________________
10. Provider name ________________________________________________ Telephone ( ______ ) ________________
     Street ____________________________________________________________________________________________
     City________________________________________________________ State_________ Zip____________________

    Certification: I certify the information above is true and correct to the best of my knowledge.
    ________________________________________________________________                                 _____ /_____ /_____
             Signature of claimant or legal representative                                                   Date

11. Legal representative __________________________________________ Telephone ( ______ ) _________________
     Street ____________________________________________________________________________________________
     City________________________________________________________ State _____________ Zip_______________
     Include copy of legal documents, if applicable

For your protection state insurance laws require the following to appear on this form: Any person who
knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may
be subject to fines and confinement in state prison.

                                         Penn Treaty Network America Insurance Company
                                (Penn Treaty Network America Life Insurance Company in California)
                                              American Network Insurance Company

                             ATTN Claims Department :: PO Box 7066 :: Allentown, PA 18105-7066
CIF 06/08

								
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