John Hancock Independent Care Provider Service Reimbursement Completed Form Examples and Samples

View a detailed example of a completed John Hancock Independent Care Provider Service Reimbursement form. This free sample demonstrates how to accurately fill out the claim for in-home care, helping you submit your long-term care insurance paperwork correctly.
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Completed John Hancock Independent Care Provider Service Reimbursement form sample for in-home care.

John Hancock Independent Care Provider Service Reimbursement Example

How this form was filled:

This is an example of a completed John Hancock Independent Care Provider Service Reimbursement form. It is submitted by a Power of Attorney on behalf of the insured for in-home personal care services provided by a licensed independent caregiver for the month of March 2026. The form details the provider's information, services rendered, hours, rates, and includes required signatures.

Information used to fill out the document:

  • Insured's Full Name: Eleanor Vance
  • Insured's Policy Number: JH-LTC-987654321
  • Insured's Date of Birth: 05/10/1946
  • Insured's Address: 456 Oak Avenue, Anytown, USA 12345
  • Submitter's Name (if not Insured): Sarah Miller
  • Submitter's Relationship to Insured: Daughter / Power of Attorney
  • Care Provider's Name: Maria Garcia
  • Provider's Professional Title/License: Licensed Practical Nurse (LPN)
  • Provider's Tax ID Number: 98-7654321
  • Provider's Address: 101 Maple Drive, Anytown, USA 12345
  • Service Period: 03/01/2026 to 03/31/2026
  • Types of Services Provided: Personal Care (Bathing, Dressing, Toileting), Medication Reminders
  • Total Days of Care: 31
  • Hours of Care Per Day: 4
  • Provider's Hourly Rate: $30.00
  • Total Reimbursement Claimed: $3,720.00
  • Date of Submission: 04/05/2026

What this filled form sample shows:

  • Clearly defined insured and submitter (Power of Attorney) information.
  • Complete care provider details, including professional license and Tax ID.
  • Detailed log of services rendered and calculation of total cost.
  • Properly dated signatures from both the provider and the insured's representative to validate the claim.

Form specifications and details:

Form Name: John Hancock Independent Care Provider Service Reimbursement
Use Case: Claim for in-home care by a non-agency, licensed caregiver.
Submitted by: Power of Attorney for the insured.
Filing Period: Monthly
Categories: health insurance forms, John Hancock forms, L.A. Care forms
Created: February 26, 2026 09:09 PM
Completed John Hancock Independent Care Provider Service Reimbursement form sample for in-home care.