Once printed, please ensure that all questions on the page are answered as completely as possible. We will also need copies of all itemized hospital bills, physician bills, and any other documentation of expenses. These bills should indicate a diagnosis code, any applicable procedure codes, as well as the date and cost of the services. If you have any prescription receipts, they must include the date, patient’s name, name of the prescribed medication, and the name of the prescribing physician.
Before you return the document to us, please ensure that the authorization section has been signed and dated. We also recommend that you keep a copy of any submitted claim forms for your records.
