Supplemental Medical Plan by joannecinc

VIEWS: 23 PAGES: 1

									                                    Supplemental Medical Plan Claim Form
                                                                           Mail completed Claim Form to:
                                                         Kanawha Insurance Company, P.O. Box 2000, Lancaster, SC 29721-2000
                                                                             Or fax to: 803-283-5545

INSURED’S STATEMENT
Your application for benefits will be delayed unless all questions are fully completed.
Patient’s Name __________________________________________ Patient’s Birthdate (mm/dd/year) _____________________________
Sex:      Male      Female             Relationship to Insured:    Self     Spouse        Child    Other __________________________________
Insured’s Name__________________________________________ Certificate Number _______________________________________
INSURED’S MAILING ADDRESS
Street________________________________________________________________________________________________________
City ______________________________________ State____________________________ ZIP ______________________________


       Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim
                       containing a false or deceptive statement is subject to prosecution and punishment for insurance fraud.

____________________________________________________________________________________ _______________________
Signature                                                                            Date (mm/dd/year)
If signed on behalf of another, indicate relationship: _____________________________________________________________________
FOR OFFICE VISIT CLAIMS
• Complete and sign the Insured’s Statement, above.
• Attach a copy of the receipt from the doctor’s office showing both a diagnosis code and a procedure code.
• Please note: If this is the first claim that you have filed, it will be delayed as we gather information from your physician(s) for a pre-existing
  condition check. To expedite this process, you may provide to us the information requested on the Pre-existing Condition Verification form
  (6275 9/06). All claims received within the first policy year will be subject to the pre-existing condition clause.
FOR ACCIDENT CLAIMS
• Complete and sign the Insured’s Statement, above.
• Attach a copy of the receipt from the doctor’s office, Emergency Room or hospital bill showing both a diagnosis code and a procedure code.
  (Please note: Treatment must be received within 72 hours of the accident for this benefit to be paid.)
• What was the date and time of the accident? _________________________________________________________________________
• Did the injury occur at work? Yes     No
• Describe how the accident happened and type of injuries sustained. ________________________________________________________
FOR HOSPITAL CLAIMS
• Complete and sign the Insured’s Statement, above.
• Attach a copy of the hospital bill showing admission and discharge dates, a diagnosis code and procedure code(s).
FOR EMERGENCY SICKNESS CLAIMS
• Complete and sign the Insured’s Statement, above.
• Attach a copy of the receipt from the Emergency Room showing both a diagnosis code and a procedure code.
FOR WELLNESS BENEFITS
The Wellness Benefit is not applicable until the coverage has been in force for at least six (6) months.
• Complete and sign the Insured’s Statement, above.
• Attach a copy of the receipt from the doctor’s office showing both a diagnosis code and a procedure code. (At least one diagnosis code must be
  a routine code for visit to be considered “wellness”.
• At least two of the following must be performed: EKG, mammogram, digital prostate exam, pap smear, cardiovascular stress test, blood
  chemistry test, urinalysis or prostate specific antigen test.
6270 9/06                               Kanawha Insurance Company is a wholly-owned subsidiary of KMG America.

								
To top