Instructions for filling your request Employer: _____________________________________

for benefits are on the reverse side. Harrington Health

P.O. BOX 30544, SALT LAKE CITY, UT 84130-0544 Policy no.: _____________________________________
CLAIM FORM

INSURED EMPLOYEE’S STATEMENT

Name of insured employee Soc. Sec. No. Date of birth Occupation

Street number City State Zip code Phone no.

Name of dependent (if patient) Date of birth Relationship to employee Is child a full-time student?
If child, is he/she employed full time? If yes, # of hours:
Yes No
Yes No
Where:
Is request for benefits being Last day worked, if disability request:
Date accident or sickness began:
made for Workers’ Compensation? Yes No
Nature of sickness, injury, diagnosis or medical call:
If injured, how and where did accident happen?
Married? Yes No Name of spouse: Soc. Sec. No. Date of birth: Is spouse employed? Yes No
Name & address of spouse’s employer

Are you or your dependent insured under any other group insurance or government plan which will also pay for any of the medical expenses of this request for benefits? Yes No
If yes, give name, address, and policy number of insurance company providing benefits. Name of policyholder:
Name & address insurance company: Policy no.:
AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN. PARTICIPANT SIGNATURE
I hereby authorize payment directly to the undersigned physician of the surgical and/or medical benefits, if any,
otherwise payable to me for his services as described below, but not to exceed the reasonable and customary
charge for those services. DATE
By furnishing this blank the plan shall not be held to admit the validity of any request for benefits or waive the breach of any condition of the plan document. I hereby authorize and request any
hospital, physician or surgeon to release to ,
or its representative, any information, record, transcript or history pertaining to treatment rendered to myself, or my dependents, by such hospital, physician or surgeon requested by the said above na
SIGNATURE (OF PATIENT) DATE
ATTENDING PHYSICIAN’S STATEMENT
Patient’s name Age

Diagnosis and concurrent conditions:

(If diagnosis code other than ICDA* used, give name)
Is condition due to injury Patient’s employment? Accidental injury? Pregnancy?
If yes, approx. date pregnancy began:
or sickness arising from: Yes No Yes No Yes No
REPORT OF SERVICES OR ATTACH ITEMIZED BILL. IF PREVIOUS FORM SUBMITTED TO THIS CARRIER, YOU NEED SHOW ONLY DATES AND SERVICES SINCE LAST REPORT.
Date of Services Place of Services Description of Surgical or Medical Services Rendered CPT Code Charges

*O - Doctor’s office IH - Inpatient hospital NH - Nursing home H - Patient’s home OH - Outpatient hospital OL - Other locations Total charges: $

*ICDA - International classification of diseases **CPT - Current procedural terminology (current edition) Amount paid: $
Balance due: $
Date symptoms first appeared or accident happened: Patient still under your care for this condition? Yes No
Date patient first consulted you for this condition: Last day worked:
Was patient referred to you by another physician? Yes No Patient was continuously totally disabled (unable to work)
If yes, give name & address From To

If still disabled, estimated date of return:

Date:
Has patient ever had same or similar condition? Yes No Date employee returned to work:
If yes, when? Describe:
Does patient have other health coverage? Yes No If yes, please identify:
Date: Physician’s name (print)
Signature: Degree: IRS or Soc. Sec. No.:
Street address City State Zip code Telephone
 PROCEDURES WHEN REQUESTING MEDICAL BENEFITS

1. You do not need to file this claim form if you use a preferred provider or a preferred
provider hospital. All preferred providers and preferred provider hospitals will file the
claim for you.

2. If you do not use a preferred provider or a preferred provider hospital, a new request for
benefits form is needed each year.

3. Complete upper portion of the form titled participating employee’s statement,

answering all questions.

4. All questions concerning spouse’s employer and other group insurance must be filled
out completely. Failure to do so will delay payment of benefits.

5. The portion of the form titled authorization to pay benefits to physician is to be signed
by you, if benefits are to be paid directly to the doctor.

6. Make a final check to see that all parts of the request for benefits form are complete
and attach all hospital and medical bills relating to the request for benefits, making
certain that:
A. All bills identify the patient and are complete and correct.
B. Physician bills show date and type of treatment and charges.
C. Nurse’s bills show date, place and hours of duty, charges per date, and nurse’s
signature.

7. Mail the request for benefits form to the address on your identification (ID) card and
please include your electronic payor number 62061.

8. When the request for benefits has been processed, you will receive verification of
action taken.

9. Please refer to your employee booklet for appeal procedures on denied claims.

10. Prescription drug claims are not filed with Harrington Health. To file prescription drug
claims filled at a non-participating pharmacy, you will need to file a prescription drug
claim form with the prescription benefit manager.

If you have any questions, please contact:

Mail: HARRINGTON HEALTH at the address on your ID card

Phone: HARRINGTON HEALTH at (316) 264-5311

Any person who knowingly and with intent to defraud an insurer files a statement of claim
containing any false, incomplete or misleading information may be guilty of insurance fraud
which is a crime.