THE RETA PLAN HEALTH CLAIM FORM
PART 1 TO BE COMPLETED BY EMPLOYEE Answer all questions below. Omitted information will cause delays.
Item 1: Complete for all claims. (Please print or type)
EMPLOYER NAME EMPLOYER ADDRESS EMPLOYER’S PHONE NO.
CLAIM IS FOR CHILD PATIENT’S NAME PATIENT’S DATE OF BIRTH IS PATIENT ELIGIBLE FOR PATIENT HOSPITALIZED?
EMPLOYEE SPOUSE YES NO YES NO
EMPLOYEE’S NAME EMPLOYEE’S DATE OF BIRTH EMPLOYEE’S SOCIAL SECURITY NUMBER
EMPLOYEE’S ADDRESS (N., Street, City, State, Zip Code)
DO YOU HAVE MORE THAN ONE EMPLOYER? (If yes, give name and address of other employer) OTHER EMPLOYER’S PHONE
YES NO ( )
NATURE OF ILLNESS OR INJURY IS THERE A PREVIOUS HISTORY OF THIS ILLNESS? IF MATERNITY CLAIM, WAS PATIENT
A.M. (If yes, give name and address of employer)_ INSURED ON DATE PREGNANCY
P.M. YES NO DATE _____/_____/_____ YES NO
Accident information – Complete this section only if claim is result of an accidental injury or occupational sickness.
DATE OF ACCIDENT TIME OF ACCIDENT WHERE DID THE ACCIDENT OCCUR? (City, State) DID THE ACCIDENT/SICKNESS HAPPEN AT
________ : ________ P.M. YES NO
DESCRIBE ACCIDENT OR OCCUPATIONAL SICKNESS
IS THERE A THIRD PARTY LIABILITY INVOLVED, IE.: WORKER’S COMP / AUTO MEDICAL / OTHER INSURANCE / PENDING LAWSUIT, ETC.? (If yes, give name, address and phone no.)
Item 2: PLEASE COMPLETE ITEMS 2 AND 3 IF YOU HAVE DEPENDENT COVERAGE
NAME OF YOUR SPOUSE SPOUSE’S SOCIAL SECURITY NUMBER SPOUSE’S DATE OF BIRTH
IS YOUR SPOUSE EMPLOYED? (If yes, give name and address of employer) EMPLOYERS PHONE NO.
YES NO ( )
NAME & ADDRESS OF SPOUSE’S GROUP HEALTH INSURANCE COMPANY
Item 3: Complete if claim is for your dependent child.
NAME OF YOUR DEPENDENT CHILD DATE OF BIRTH IS DEPENDENT CHILD
HANDICAPPED STUDENT Give name and
OTHER location of school. _________________________
IS DEPENDENT CHILD EMPLOYED? (If yes, give name and address of employer) EMPLOYER’S PHONE NO.
YES NO ( )
NAME & ADDRESS OF DEPENDENT CHILD’S GROUP HEALTH INSURANCE COMPANY
Item 4: Complete for all claims.
I HEREBY CERTIFY than the above statements are complete and accurate to the best of my knowledge. I also agree to reimburse Pacific Administrators (PAA), to the extent of any overpayment which is
in excess of the amounts payable under the Plan.
I AUTHORIZE all medical practitioners, hospitals and other medical or medically related facilities having information as to diagnosis, treatment and prognosis with respect to any physical or mental
condition and/or treatment for me or my minor children to give all such information to PAA. For purposes of coordination of benefits, I also authorize any union, trust fund, employer, insurance carrier or
service organization to furnish PAA with information regarding benefits to which I may be entitled.
I UNDERSTAND that the information obtained by use of this Authorization will be used by PAA to determine eligibility for benefits under the Plan, information obtained will not be released by PAA except
to insurance or reinsurance carriers or to persons or organizations performing business or legal services relating to the claim or as may be lawfully required or as I may further authorize.
I KNOW that I have the right to receive a copy of this Authorization upon request from PAA. I AGREE that a photocopy of this Authorization shall be as valid as the original, and will be valid for two years
from the date shown below.
DATE SIGNATURE (PATIENT OR PARENT IF MINOR)
Mail ALL HOSPITAL CLAIMS TO: All Other Claims to:
Completed The RETA Plan Pacific Atlantic Administrators
Form c/o Pacific Atlantic Administrators P.O. Box 7407
P.O. Box 10069 San Francisco, CA 94120
SCOTTSDALE, AZ 85271-0069 (415) 495-4340 (800) 877-7474
G:\RETA\CLAIM FORM.DOC PG. 1 (Rev. 03/22/01)
PART 2 AUTHORIZATION TO PAY BENEFITS TO THE PROVIDER
AUTHORIZATION TO PAY BENEFITS TO THE PROVIDER. I hereby authorize payment directly to the
Provider of the Surgical and or Medical Benefits, if any, otherwise payable to me for the services as
described below or on the attached bills but not to exceed the reasonable and customary charge for those
services. __________________________________________ _____________________
SIGNATURE (EMPLOYEE) DATE
PART 3 TO BE COMPLETED BY ATTENDING PHYSICIAN
HAVE YOUR PHYSICIAN COMPLETE PART 3 OR
ATTACH ITEMIZED BILLS FOR EXPENSES NOT REPORTED ON THIS FORM. ALL SUCH BILLS MUST SHOW:
a. Employee’s Name d. Diagnosis g. Dates (month, day, year) of Services
b. Patient’s Name (if not employee) e. Complete Description of Services Rendered
c. Name & Address of Provider of Services f. Initials of Attending or Prescribing Physician
14. DATE OF ILLNESS (FIRST SYMPTOM) OR INJURY 15. DATE FIRST CONSULTED YOU FOR 16. HAS PATIENT EVER HAD SAME OR SIMILAR SYMPTOMS?
(ACCIDENT) OR PREGENCY (LMP) THIS CONDITION YES NO
17. DATE PATIENT ABLE TO 18. DATE OF TOTAL DISABILITY DATE OF PARTIAL DISABILITY
RETURN TO WORK
FROM THROUGH FROM THROUGH
19. NAME OF REFERRING PHYSICIAN 20. FOR SERVICES RELATED TO HOSPITALIZATION
GIVE HOSPITALIZATION DATES
21. NAME & ADDRESS OF FACILITY WHERE SERVICES RENDERED (If other than home or office) 22. WAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE?
23. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATE DIAGNOSIS TO PROCEDURE IN COLUMN BY REFERENCE TO NUMBERS 1,2,3 ETC. OR DX CODE
24. A B* C FULLY DESCRIBED PROCEDURES, MEDICAL SERVICES OR SUPPLIES D E
DATE PLACE FURNISHED FOR EACH DATE GIVEN ICDA CHARGES
OF OF PROCEDURE CODE DIAGNOSIS
SERVICE SERVICE (IDENTIFY: ) (Explain Unusual Services or Circumstances) CODE
25. SIGNATURE OF PHYSICIAN OR SUPPLIER 26. ACCEPT ASSIGNMENT 27. TOTAL CHARGES 28. AMT. PAID 29. BAL DUE
30. YOUR SOCIAL SECURITY NO. 1 31. PHYSICIAN’S OR SUPPLIER’S NAME, ADDRESS, ZIP CODE &
32. YOUR PATIENT’S ACCOUNT NO. 33. YOUR EMPLOYER I.D. NO. 2
*PLACE OF SERVICE CODES
1 – (H) – Inpatient 4 – (H) – Patient’s Home 7 – (NH) Nursing Home O – (OL) - Other Locations
2 – (OH) – Outpatient Hospital 5- Day Care Facility 8 – (SNF) Skilled Nursing Facility A – (IL) - Independent Laboratory
3 – (O) – Doctor’s Office 6- Night Care Facility (PSY) 9- Ambulance B- Other Medical/Surgical Facility
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