"Statement of Claim Form - Selmanco"

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P.O. Box 2510
Rockville, Maryland 20847-2510
1-800-638-2610
Underwritten by Monumental Life Insurance Company
STATEMENT OF CLAIM
INSTRUCTIONS ON HOW TO SUBMIT A TRICARE/CHAMPVA SUPPLEMENT CLAIM
1. The form must be completed by the Member and;
2. Send the appropriate medical bills, hospital bills and all Explanation of Benefits worksheets from TRICARE/CHAMPVA
to: Claims Department, Group Insurance Administrator, P.O. Box 2510 Rockville, Maryland 20847-2510
3. TRICARE Prime claimants must submit a receipt from the provider of care showing the paid co-payment amount.
Name of Member
Member ID#
Sex
Male
Female
Date of Birth
Social Security Number
Marital Status
Single
Married
Other___________________
Address (Street, City, State & Zip Code)
Name of Association/Organization/Credit Union/Employer
Type of Claim:
Prime
Standard
CHAMPVA
TRICARE
TRICARE
Name of Patient
Relationship to Member
Date of Birth
Spouse
Daughter
Son
Other
Address of Patient (Street, City, State & Zip Code)
Nature of Accident or Illness - Describe
Have you claimed benefits for this condition previously?
No
Yes If Yes, when? ________________
Assignment of Benefits
I hereby authorize payment of eligible benefits under my policy in connection with this injury or illness to:
Name of Provider of Care (Doctor, Hospital, etc.) ______________________________________________________________
_______________________________________
___________________________________
_______________
Signature of Patient or Guardian
Relationship to Patient if Signed by Guardian
Date
LC-7363-1 (MLIC)
Page 1 of 2
9/2012
P.O. Box 2510
Rockville, Maryland 20847-2510
1-800-638-2610
Underwritten by Monumental Life Insurance Company
STATEMENT OF CLAIM
INSTRUCTIONS ON HOW TO SUBMIT A TRICARE/CHAMPVA SUPPLEMENT CLAIM
1. The form must be completed by the Member and;
2. Send the appropriate medical bills, hospital bills and all Explanation of Benefits worksheets from TRICARE/CHAMPVA
to: Claims Department, Group Insurance Administrator, P.O. Box 2510 Rockville, Maryland 20847-2510
3. TRICARE Prime claimants must submit a receipt from the provider of care showing the paid co-payment amount.
Name of Member
Member ID#
Sex
Male
Female
Date of Birth
Social Security Number
Marital Status
Single
Married
Other___________________
Address (Street, City, State & Zip Code)
Name of Association/Organization/Credit Union/Employer
Type of Claim:
Prime
Standard
CHAMPVA
TRICARE
TRICARE
Name of Patient
Relationship to Member
Date of Birth
Spouse
Daughter
Son
Other
Address of Patient (Street, City, State & Zip Code)
Nature of Accident or Illness - Describe
Have you claimed benefits for this condition previously?
No
Yes If Yes, when? ________________
Assignment of Benefits
I hereby authorize payment of eligible benefits under my policy in connection with this injury or illness to:
Name of Provider of Care (Doctor, Hospital, etc.) ______________________________________________________________
_______________________________________
___________________________________
_______________
Signature of Patient or Guardian
Relationship to Patient if Signed by Guardian
Date
LC-7363-1 (MLIC)
Page 1 of 2
9/2012
FRAUD WARNING NOTICES
Any person who knowingly and with intent to defraud, injure or deceive an insurance company or other person files a statement of
claim or application containing any materially false or misleading information or conceals for the purpose of misleading, information
concerning any fact material thereto, may be guilty of a crime and may be subject to civil penalties, fines, and/or imprisonment.
Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or
any combination thereof.
Alaska, Minnesota, New Hampshire: A person who knowingly and with intent to injure, defraud, or deceive an insurance company
files a claim containing false, incomplete, or misleading information may be prosecuted under state law.
Arkansas, Louisiana, New Mexico, Texas, West Virginia: Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to civil fines and criminal penalties.
Arizona: For your protection Arizona law requires the following statement to appear on this form: Any person who knowingly presents
a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
California: For your protection California law requires the following to appear on this form: Any person who knowingly presents false
or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to any insurance company for the
purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil
damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or
information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard
to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the
Department of Regulatory Agencies.
Maine, Virginia, Tennessee, Washington: It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company or any other person. Penalties include imprisonment and/or fines. In
addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
Delaware, Idaho, Indiana: Any person who knowingly, and with intent to injure, defraud or deceive any insurer files a statement of
claim containing any false or misleading information is guilty of a felony.
Florida: Any person who knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or
self insured program files a statement of claim or an application containing any false or misleading information commits insurance
fraud, punishable as provided in section 817.234.
District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding
the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if
false information materially related to a claim was provided by the applicant.
Oklahoma: Warning: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the
proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Kentucky, Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person, files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to
criminal and civil penalties.
Maryland: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who
knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison.
New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to
criminal and civil penalties.
New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information
concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty
not to exceed five thousand dollars and the stated value of the claim for each violation.
Ohio: 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 guilty of insurance fraud.
Oregon: Any person who knowingly and with intent to defraud, files a claim for benefits may be guilty of insurance fraud and may be
subject to prosecution.
LC-7363-1 (MLIC)
Page 2 of 2
9/2012
Page of 2