Meritain Health Claim Form (Health Claim Form) Instructions
This form contains 227 fields organized into 33 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Accident Confirmation | ||
| checkbox_c4c3_f964 | CheckBox | |
| checkbox_a57f_3014 | CheckBox | |
| Accident Confirmation Yes | Checkbox |
Check this box if the injury was the result of an accident.
|
| Accident Confirmation No | Checkbox |
Check this box if the injury was not the result of an accident.
|
| Assignment of Benefits | ||
| text_5939_8dc3 | Text | |
| text_f70b_4c35 | Text | |
| text_d204_af30 | Text | |
| Provider to be Paid | Text |
Enter the name of the provider who should receive the payment of benefits directly.
|
| Provider's Tax ID or Social Security Number | Text |
Enter the provider's tax identification number or Social Security Number.
|
| Assignment Date | Date |
Enter the date the assignment of benefits was signed.
|
| Auto Insurance Information | ||
| text_3f0e_bbb2 | Text | |
| text_24ce_9647 | Text | |
| text_e8dd_d61b | Text | |
| Auto Insurance Policy Number | Text |
Enter the policy number of the auto insurance involved.
|
| Auto Insurance Company Name | Text |
Enter the name of the auto insurance company involved.
|
| Auto Insurance Company Address | Text |
Enter the address of the auto insurance company involved, including city, state, and zip code.
|
| Child Information | ||
| text_c635_5848 | Text | |
| text_f844_b71f | Text | |
| text_20b3_d45f | Text | |
| text_d69f_21bc | Text | |
| Child's Name | Text |
Please provide the child's full name, including last name, first name, and initial.
|
| Child's Sex | Text |
Please provide the child's sex.
|
| Child's Birthdate | Date |
Please provide the child's birthdate.
|
| Child's Social Security Number | Text |
Please provide the child's Social Security Number.
|
| Claim Reason | ||
| checkbox_f3d5_79f6 | CheckBox | |
| checkbox_824d_dc00 | CheckBox | |
| 3 Injury | Checkbox |
Check this box if the claim is for an injury.
|
| 4 Illness | Checkbox |
Check this box if the claim is for an illness.
|
| Condition Treatment Dates | ||
| text_d02b_917a | Text | |
| text_def3_3a51 | Text | |
| Condition Treatment: Date of First Treatment | Date |
Enter the date when the first treatment for the illness occurred.
|
| Condition Treatment: Date of Injury | Date |
Enter the date of the injury if the condition is being treated due to an injury.
|
| Diagnosis Conditions | ||
| text_9f24_14f7 | Text | |
| text_4377_02b8 | Text | |
| text_e0bc_c05e | Text | |
| text_4751_997a | Text | |
| Diagnosis Condition 1 | Text |
Provide the first diagnosis condition or name if diagnosis other than ICD-10* is used.
|
| Diagnosis Condition 2 | Text |
Provide the second diagnosis condition or name if diagnosis other than ICD-10* is used.
|
| Diagnosis Condition 3 | Text |
Provide the third diagnosis condition or name if diagnosis other than ICD-10* is used.
|
| Diagnosis Condition 4 | Text |
Provide the fourth diagnosis condition or name if diagnosis other than ICD-10* is used.
|
| Employee Information | ||
| text_5e84_150b | Text | |
| text_fd9a_c0cb | Text | |
| text_ad5a_5796 | Text | |
| text_11b0_06d0 | Text | |
| text_4592_1712 | Text | |
| text_f33a_e390 | Text | |
| text_196c_dc20 | Text | |
| text_6ea0_9953 | Text | |
| text_b11b_bf1d | Text | |
| text_dc5a_217b | Text | |
| text_069f_3ccc | Text | |
| text_e135_86c6 | Text | |
| text_c2c4_54e4 | Text | |
| text_d653_a797 | Text | |
| Employee Name | Text |
Please provide the employee's full name, including last name, first name, and middle initial.
|
| Employee Sex | Text |
Please provide the employee's biological sex.
|
| Employer Name | Text |
Please provide the name of the employee's employer.
|
| Employee Identification Number | Text |
Please provide the employee's identification number.
|
| Employee Birthdate | Date |
Please provide the employee's date of birth.
|
| Employee Group Number | Text |
Please provide the employee's group number.
|
| Employee Home Address | Text |
Please provide the employee's full home address.
|
| Employee State | Text |
Please provide the two-letter abbreviation for the employee's home state.
|
| Employee City | Text |
Please provide the city of the employee's home address.
|
| Employee Zip Code | Text |
Please provide the zip code of the employee's home address.
|
| Employee Work Telephone Area Code | Text |
Please provide the area code for the employee's work telephone number.
|
| Employee Home Telephone Number | Text |
Please provide the main seven-digit number for the employee's home telephone number.
|
| Employee Work Telephone Number | Text |
Please provide the main seven-digit number for the employee's work telephone number.
|
| Employee Home Telephone Area Code | Text |
Please provide the area code for the employee's home telephone number.
|
| Employee Signature Date | ||
| text_9071_8005 | Text | |
| Employee Signature Date | Date |
Provide the date the employee signed the form.
|
| Employment Injury Status | ||
| checkbox_5562_5fde | CheckBox | |
| checkbox_aba4_1faf | CheckBox | |
| Employment Injury Status - No | Checkbox |
Check this box if the patient's medical condition is not the result of an injury that occurred during their employment.
|
| Employment Injury Status - Yes | Checkbox |
Check this box if the patient's medical condition is the result of an injury that occurred during their employment.
|
| External Laboratory Work Status | ||
| checkbox_48c6_5e4a | CheckBox | |
| checkbox_1eb3_f3f5 | CheckBox | |
| Yes | Checkbox |
Check this box if laboratory work was performed outside your office.
|
| No | Checkbox |
Check this box if laboratory work was not performed outside your office.
|
| First Service Details | ||
| text_b409_30db | Text | |
| text_1a83_f337 | Text | |
| text_9a32_99d7 | Text | |
| text_dnjCNO_40e9 | Text | |
| text_cCRG8n_a89d | Text | |
| text_OZ1TbX_84f9 | Text | |
| First Service Procedure Code | Text |
Enter the procedure code for the first service, or if other than CPT code, provide its name.
|
| First Service Description | Text |
Provide a description of the surgical or medical services rendered for the first service.
|
| First Service Date From | Date |
Enter the start date for the first service provided.
|
| First Service Place | Text |
Enter the place where the first service was rendered.
|
| First Service Diagnosis Code | Text |
Enter the diagnosis code for the first service.
|
| First Service Charges | Number |
Enter the total charges for the first service.
|
| Fourth Service Details | ||
| text_01ea_f363 | Text | |
| text_14e5_50fe | Text | |
| text_a1e7_7a96 | Text | |
| text_OSOWOR_005c | Text | |
| text_Ttw1GA_631d | Text | |
| text_LghtUT_6836 | Text | |
| Fourth Service From Date | Date |
Provide the start date for the fourth service.
|
| Fourth Service Procedure Code | Text |
Enter the procedure code for the fourth service, or its name if not a CPT code.
|
| Fourth Service Description | Text |
Describe the surgical or medical services rendered for the fourth service.
|
| Fourth Service Place of Service | Text |
Enter the code indicating the place where the fourth service was rendered.
|
| Fourth Service Diagnosis Code | Text |
Enter the diagnosis code applicable to the fourth service.
|
| Fourth Service Charges | Number |
Enter the total charges for the fourth service.
|
| Hospitalization Dates | ||
| text_6204_5434 | Text | |
| text_fad0_3e8d | Text | |
| Discharge Date | Date |
Enter the date the patient was discharged from the hospital.
|
| Admission Date | Date |
Enter the date the patient was admitted to the hospital.
|
| Incident Details | ||
| text_9d58_64bd | Text | |
| text_ef47_29d2 | Text | |
| Accident Date | Date |
Enter the date of the accident.
|
| Incident Description | Text |
Provide a detailed description of the injury, including when and how it happened, or the nature of the illness.
|
| Other Coverage Confirmation | ||
| checkbox_0b76_c044 | CheckBox | |
| checkbox_023a_1a78 | CheckBox | |
| Yes | Checkbox |
Check this box if there is other health insurance coverage for the patient.
|
| No | Checkbox |
Check this box if there is no other health insurance coverage for the patient.
|
| Other Insurance Policy Details | ||
| text_3629_1b18 | Text | |
| text_c053_0ccd | Text | |
| text_9e21_96da | Text | |
| text_2d6f_9434 | Text | |
| text_1708_d31a | Text | |
| text_7fee_d3ae | Text | |
| text_78ee_2304 | Text | |
| text_d082_e04d | Text | |
| text_fce9_e75e | Text | |
| Other Insurance Policy Holder Name | Text |
Enter the name of the policy holder for the other health insurance policy.
|
| Other Insurance Carrier or Plan Name | Text |
Enter the name of the other health insurance carrier or plan.
|
| Other Insurance Carrier Address | Text |
Enter the street address of the other health insurance carrier or plan.
|
| Other Insurance Carrier City | Text |
Enter the city of the other health insurance carrier or plan.
|
| Other Insurance Carrier State | Text |
Enter the state of the other health insurance carrier or plan.
|
| Other Insurance Carrier Zip Code | Text |
Enter the zip code of the other health insurance carrier or plan.
|
| Other Insurance Carrier Phone Number | Text |
Enter the telephone number of the other health insurance carrier or plan.
|
| Other Insurance Contract or Policy Number | Text |
Enter the contract or policy number for the other health insurance.
|
| Other Insurance Group Number | Text |
Enter the group number for the other health insurance policy.
|
| Patient Address | ||
| text_4167_4a46 | Text | |
| Patient Address | Text |
Provide the full mailing address of the patient, including street, city, state, and zip code.
|
| Patient Identity Selection | ||
| checkbox_6271_4673 | CheckBox | |
| checkbox_7aa4_fb7f | CheckBox | |
| checkbox_3451_ecaa | CheckBox | |
| The employee | Checkbox |
Check this box if the patient is the employee.
|
| Employee's Spouse | Checkbox |
Check this box if the patient is the employee's spouse.
|
| Employee's Child | Checkbox |
Check this box if the patient is the employee's child.
|
| Patient Information | ||
| text_be62_0205 | Text | |
| text_ced9_f981 | Text | |
| Patient Name | Text |
Enter the patient's full name, including their last name, first name, and initial.
|
| Patient Birthdate | Date |
Enter the patient's date of birth.
|
| Patient Information Section | ||
| text_aee3_0368 | Text | |
| Physician Address | ||
| text_acce_faaa | Text | |
| text_be48_73f1 | Text | |
| text_be33_fd25 | Text | |
| text_f879_cd54 | Text | |
| Physician City | Text |
Enter the city of the physician's address.
|
| Physician Street Address | Text |
Enter the street address of the physician.
|
| Physician State | Text |
Enter the state of the physician's address.
|
| Physician Zip Code | Text |
Enter the zip code of the physician's address.
|
| Physician Details | ||
| text_1e34_6805 | Text | |
| text_5c85_251a | Text | |
| text_6e64_6a34 | Text | |
| text_df92_985a | Text | |
| text_aaf4_1460 | Text | |
| text_2d2b_bfcb | Text | |
| Signature Date | Date |
Enter the date the physician signed the form.
|
| Physician's Printed Name | Text |
Enter the physician's full name, printed clearly.
|
| Physician's Degree | Text |
Enter the physician's academic degree or professional designation.
|
| Physician's Signature | Text |
Enter the physician's full name as their signature.
|
| Physician's Phone Number (Main) | Text |
Enter the main part of the physician's telephone number, including the prefix and line number.
|
| Physician's Phone Number (Area Code) | Text |
Enter the area code for the physician's telephone number.
|
| Pregnancy Information | ||
| checkbox_8586_b2e0 | CheckBox | |
| checkbox_ab0d_7b33 | CheckBox | |
| text_ef16_6d91 | Text | |
| Pregnancy Yes | Checkbox |
Check this box if the patient is pregnant.
|
| Pregnancy No | Checkbox |
Check this box if the patient is not pregnant.
|
| Expected Date of Delivery | Date |
Provide the expected date of delivery if the patient is pregnant.
|
| Provider's Tax ID | ||
| text_WjKr1Z_52d9 | Text | |
| Provider's Tax ID or Social Security Number | Text |
Enter the provider's Tax ID Number or Social Security Number.
|
| Referring Physician Information | ||
| text_1c39_cffa | Text | |
| text_3835_1d65 | Text | |
| Referring Physician Name | Text |
Enter the full name of the referring physician.
|
| Referring Physician Address | Text |
Enter the complete mailing address of the referring physician.
|
| Second Service Details | ||
| text_4079_da86 | Text | |
| text_3e65_509d | Text | |
| text_7e6e_618a | Text | |
| text_30pxq5_8905 | Text | |
| text_RWfv5B_7b8e | Text | |
| text_cI9sF3_10fe | Text | |
| Service 2 Dates From | Date |
Enter the start date for the second service.
|
| Service 2 Procedure Code | Text |
Enter the procedure code for the second service, or the name if not a CPT code.
|
| Service 2 Description | Text |
Provide a detailed description of the surgical or medical services rendered for the second service.
|
| Service 2 Place of Service Code | Text |
Enter the code indicating where the second service was rendered.
|
| Service 2 Diagnosis Code | Text |
Enter the diagnosis code for the second service.
|
| Service 2 Charges | Number |
Enter the total charges for the second service.
|
| Service Facility and Address | ||
| text_5386_8fe9 | Text | |
| Service Facility Name and Address | Text |
Provide the name and full address of the facility where services were rendered, if it was not performed at the patient's home or the provider's office.
|
| Spouse Information | ||
| text_8d51_ccfd | Text | |
| text_f41e_aebd | Text | |
| text_cff8_1b30 | Text | |
| text_1602_ee13 | Text | |
| text_4f33_e5f5 | Text | |
| text_a618_e7e6 | Text | |
| Spouse's Name | Text |
Please provide the spouse's full name, including their last name, first name, and initial.
|
| Spouse's Sex | Text |
Please provide the spouse's sex.
|
| Spouse's Birthdate | Date |
Please provide the spouse's date of birth.
|
| Spouse's Social Security Number | Text |
Please provide the spouse's Social Security Number.
|
| Spouse's Employer | Text |
Please provide the name of the spouse's employer.
|
| Spouse's Employer's Address | Text |
Please provide the complete address of the spouse's employer.
|
| Spouse's Employer For Other Coverage | ||
| text_3a5c_fc84 | Text | |
| text_030f_5489 | Text | |
| Spouse's Employer | Text |
Enter the name of your spouse's employer.
|
| Spouse's Employer Address | Text |
Enter the complete mailing address of your spouse's employer.
|
| Third Service Details | ||
| text_257d_2bfd | Text | |
| text_38c4_88c3 | Text | |
| text_cb64_266c | Text | |
| text_4oLJGZ_274e | Text | |
| text_Gbj4Tc_ce8b | Text | |
| text_6c1CHl_bcff | Text | |
| Third Service Date From | Date |
Enter the start date for the third service provided.
|
| Third Service Place of Service | Text |
Enter the place of service code for the third service provided.
|
| Third Service Procedure Code | Text |
Enter the procedure code for the third service provided.
|
| Third Service Date To | Date |
Enter the end date for the third service provided.
|
| Third Service Diagnosis Code | Text |
Enter the diagnosis code for the third service provided.
|
| Third Service Charges | Number |
Enter the charges for the third service provided.
|
| Type of Coverage | ||
| checkbox_524e_b2b0 | CheckBox | |
| checkbox_f294_31cf | CheckBox | |
| Group | Checkbox |
Check this box if the other health insurance is a group coverage plan.
|
| Individual | Checkbox |
Check this box if the other health insurance is an individual coverage plan.
|
| Work-Related Injury Confirmation | ||
| checkbox_c055_249e | CheckBox | |
| checkbox_18b2_2e5f | CheckBox | |
| Work-Related Injury Confirmation Yes | Checkbox |
Check this box if the injury was work-related.
|
| Work-Related Injury Confirmation No | Checkbox |
Check this box if the injury was not work-related.
|