Health Insurance Claim
1. Personal Information
Name: [Your Name]
Email: [Your Email]
Policy Number: 123456789
Group Number: 67890
2. Insurance Information
3. Medical Information
Date of Service: July 15, 2054
Provider’s Name: Dr. Emily Johnson
Provider’s Address: 321 Pine Street, Metropolis, NY 10002
Diagnosis: Influenza
Treatment Provided: Consultation, Flu Test, Prescription
4. Expense Details
Description | Amount |
|---|
Consultation Fee | $120.00 |
Flu Test | $45.00 |
Prescription | $30.00 |
Total Amount Incurred | $195.00 |
5. Claim Details
Total Amount Claimed: $195.00
Deductible Amount (if applicable): $40.00
Amount Covered by Insurance: $155.00
6. Authorization and Signature
I authorize HealthCare Plus Insurance to process this claim and release any necessary medical information to facilitate payment. I certify that the information provided is accurate and that the expenses incurred are covered under my policy.
Name: [Your Name]
Date: [Date Signed]
7. Additional Information
Instructions for Submission
Submit this completed form, along with all required documentation, to the address provided by HealthCare Plus Insurance.
Keep a copy of the completed claim form and all documents for your records.
Insurance Claim Templates @ Template.net
