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Medical Claim

Employee Information

If you have checked Yes to any of the above, please provide...
If you are covered by Medicare, or any other basic hospitalization or surgical plan such as Blue Cross-Blue Shield, please submit these carrier’s payment statements or declinations along with itemized bills.

Complete For Injury Or Illness

If Claim For Dependent, Complete This Section Also

Important – Please Complete Authorization Section

The above answers are true and correct to the best of my knowledge. I hereby authorized any physician, surgeon, practitioner or other person, any hospital, including veterans administration or government hospital, any medical service organization, any insurance company, or any other institution or organization to release to each other any medical or other information acquired, including benefits paid or payable, concerning this or other disabilities. A Photostat of this authorization shall be as valid as the original.
I hereby assign my rights to benefits (including all rights arising under § 514(a) of ERISA, 29 U.S.C. §1144(a)) to, and authorize payment directly to, the Physician named above for those benefits to which the Plan Member is entitled, provided the benefits paid do not exceed the Physician’s regular charges. I understand I am financially responsible to the Physician for charges not covered by this assignment.
Vision Claim

Employee Information

If Claim For Dependent, Complete This Section Also

Complete for Vision Services Or Attach Itemized Bill

   Upload Physician's Signed and Dated Prescription

Complete for Vision Supplies Or Attach Itemized Bill

   Upload Supplier's Signed and Dated Note

Important – Please Complete Authorization Section

The above answers are true and correct to the best of my knowledge. I hereby authorized any physician, surgeon, practitioner or other person, any hospital, including veterans administration or government hospital, any medical service organization, any insurance company, or any other institution or organization to release to each other any medical or other information acquired, including benefits paid or payable, concerning this or other disabilities. A Photostat of this authorization shall be as valid as the original.
I hereby assign my rights to benefits (including all rights arising under § 514(a) of ERISA, 29 U.S.C. §1144(a)) to, and authorize payment directly to, the Physician named above for those benefits to which the Plan Member is entitled, provided the benefits paid do not exceed the Physician’s regular charges. I understand I am financially responsible to the Physician for charges not covered by this assignment.
Other Insurance
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Covered Dependents Without Other Insurance Coverage (optional)

Please list the Name and Date of Birth for all covered dependents who do not have other insurance:
I declare under penalty of perjury that the above statements are true and complete to the best of my knowledge.
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