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CARRIER HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE 08/05 PICA MEDICARE MEDICAID Medicare TRICARE CHAMPUS Sponsor s SSN Medicaid GROUP HEALTH PLAN SSN or ID CHAMPVA Member ID 3. AUTO ACCIDENT PLACE State c. OTHER ACCIDENT c. INSURANCE PLAN NAME OR PROGRAM NAME NO YES d. IS THERE ANOTHER HEALTH BENEFIT PLAN 10d. RESERVED FOR LOCAL USE READ BACK OF FORM BEFORE COMPLETING SIGNING THIS FORM. 12. PATIENT S OR AUTHORIZED PERSON S SIGNATURE I authorize the release of any...
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Video instructions and help with filling out and completing claim form
we'll hear a conversation between an officer of the small claims tribunal and a consumer who wants to make a claim first you have some time to look at questions 1 to 6 you you will see that there is an example that has been done for you on this occasion only the conversation relating to this will be played first good afternoon how can I help you good afternoon I'd like to lodge a claim certainly named Emily Jane Appleby Appleby that's an unusual name sorry what did you say your first name was again Emily Jane the woman gave her first name as Emily Jane so Emily Jane has been written in the space now we shall begin you should answer the questions as you listen because you will not hear the recording a second time listen carefully and answer questions 1 to 6 good afternoon how can I help you good afternoon I'd like to lodge a claim certainly named Emily Jane Appleby Appleby that's an unusual name sorry what did you say your first name was again Emily Jane now Miss Appleton could you please fill in this claim form I've never done that before can you help me yes of course the first part is for your the claimants details where do you live um at one your Rangga Street Durham how do you spell Durham DUI H am of course I should know that that it's just one of those names that sounds quite different from the way you spell it it is confusing I've seen it spelt with two R's and what's the postcode for Durham for 105 good and do you work no not at the moment okay so no work number what about a home phone number yes I can give you that it's seven eight four eight three seven six two seven eight four eight three seven six two right now this part here is for the respondents details who's the respondent the individual person company or business that you're claiming against is the claim against a landlord-tenant trader or driver well it's a company that sells home appliances so that's trader then just a moment while I write that down ABC appliances actually oh now this part is really important if the respondent is a company you must have the company's full and correct name and registered address I've looked it up on the internet and it's ABC appliances limited good if we don't get this part absolutely right you won't have a legal claim and registered address yes I've got that written down here just a minute it's um 17 Brown Avenue that's in Barden isn't it I think I know the place my wife bought a vacuum cleaner there last month yes Barden have you got the postcode for Barden it's really similar to mine wait a moment I'd better make sure I get it right four zero six five that's it and what's the telephone number for ABC appliances Oh seven two three two four six eight one good got that now in the third part of this form we get to the actual goods or services that are in dispute I assume he made a purchase from them yes that's right on the 3rd of...