Meritain Health Claim Form (Health Claim Form) Instructions

Enter the date (and time if known) when the injury or illness occurred.

Check this box when the claim is for an injury (not an illness).

Check this box when the claim is for an illness (not an injury).

Provide a brief description of the injury or illness, including when it occurred and how it happened (or the nature of the illness).

Check this box if the injury was the result of an accident. Fill only if 'Injury' is 'Yes'.

Check this box if the injury was not the result of an accident. Fill only if 'Injury' is 'Yes'.

Enter the full name of the doctor or supplier who should receive payment for the services.

Enter the provider's tax identification number or social security number used for payment/processing.

Enter the date when the assignment of benefits was signed or authorized.

Enter the insurance policy number assigned to the auto insurance that covered this claim.

Enter the full legal name of the auto insurance company that provided the policy.

Enter the city, state and ZIP code for the insurance company's mailing address.

Enter the first diagnosis or current medical condition for the patient; include the ICD-10 code or the diagnosis name if an ICD-10 code is not used.

Enter the second diagnosis or current medical condition for the patient; include the ICD-10 code or the diagnosis name if an ICD-10 code is not used.

Enter the third diagnosis or current medical condition for the patient; include the ICD-10 code or the diagnosis name if an ICD-10 code is not used.

Enter the fourth diagnosis or current medical condition for the patient; include the ICD-10 code or the diagnosis name if an ICD-10 code is not used.

Enter the employee's full name as last name, first name, and middle initial.

Enter the employee's sex (for example, M or F).

Enter the name of the employee's employer or company.

Enter the employee's identification number assigned by the insurer or employer (for example, member ID).

Enter the employee's date of birth.

Enter the employer or insurance group number shown on the employee's insurance information.

Enter the employee's home street address, including apartment or unit number if applicable.

Enter the U.S. state or territory for the employee's home address (use the postal abbreviation if available).

Enter the city for the employee's home address.

Enter the ZIP code for the employee's home address.

Enter the 3-digit area code for the employee's work telephone number.

Enter the employee's home telephone number excluding the area code and include extension if applicable.

Enter the employee's work telephone number excluding the area code and include extension if applicable.

Enter the 3-digit area code for the employee's home telephone number.

Enter the date on which the employee (or adult dependent) signed the form.

Check this box if the condition is not the result of an injury arising from the patient’s employment.

Check this box if the condition is the result of an injury arising from the patient’s employment.

Enter the date the patient was discharged from the hospital for this service. Fill only if 'Service Line 1 - Place of Service (POS) Code', 'Service Line 2 - Date of Service (To)', 'Service Line 3 - Date To', 'Service Line 4 - Place of Service' is '21' (any).

Enter the date the patient was admitted to the hospital for this service. Fill only if 'Service Line 1 - Place of Service (POS) Code', 'Service Line 2 - Date of Service (To)', 'Service Line 3 - Date To', 'Service Line 4 - Place of Service' is '21' (any).

Check this box if laboratory work related to this claim was performed outside your office.

Check this box if laboratory work related to this claim was not performed outside your office.

Enter the full name of the person who holds the other insurance policy (last, first, middle initial as applicable). Fill only if 'Yes (then complete)' is 'Yes'.

Check this box if the patient has other health insurance or coverage; if checked, complete the rest of Section 3.

Check this box if the patient does not have any other health insurance or coverage; if checked, skip to Section 4.

Enter the full name of the other health insurance carrier or plan. Fill only if 'Yes (then complete)' is 'Yes'.

Enter the mailing street address for the other insurance carrier or plan. Fill only if 'Yes (then complete)' is 'Yes'.

Enter the city for the other carrier or plan's mailing address. Fill only if 'Yes (then complete)' is 'Yes'.

Enter the state (postal abbreviation is acceptable) for the carrier or plan's address. Fill only if 'Yes (then complete)' is 'Yes'.

Enter the ZIP code for the other carrier or plan's mailing address. Fill only if 'Yes (then complete)' is 'Yes'.

Enter the telephone number for the other insurance carrier or plan, including area code. Fill only if 'Yes (then complete)' is 'Yes'.

Enter the contract or policy number assigned by the other insurance company. Fill only if 'Yes (then complete)' is 'Yes'.

Enter the group or employer group number associated with the other coverage, if applicable. Fill only if 'Yes (then complete)', 'Group' is 'Yes' if all.

Check this box if the other coverage is a group or employer-sponsored insurance plan. Fill only if 'Yes (then complete)' is 'Yes'.

Check this box if the other coverage is an individual policy purchased by the policyholder (not a group/employer plan). Fill only if 'Yes (then complete)' is 'Yes'.

Enter the full name of the spouse’s employer as it appears on insurance or employment records. Fill only if 'Yes (then complete)' is 'Yes'.

Enter the complete mailing address of the spouse’s employer, including street address, suite or floor if applicable. Fill only if 'Yes (then complete)' is 'Yes'.

Enter the child's full name, including first name, last name, and middle initial (if any). Fill only if 'Employee’s Child' is 'Yes'.

Enter the child's sex (for example, M or F or male or female). Fill only if 'Employee’s Child' is 'Yes'.

Enter the child's date of birth. Fill only if 'Employee’s Child' is 'Yes'.

Enter the child's Social Security Number exactly as issued (include dashes if available). Fill only if 'Employee’s Child' is 'Yes'.

Enter the spouse's full name (last name, first name, middle initial) as it appears on legal records. Fill only if 'Employee’s Spouse' is 'Yes'.

Enter the spouse's sex (for example, Male or Female). Fill only if 'Employee’s Spouse' is 'Yes'.

Provide the spouse's date of birth. Fill only if 'Employee’s Spouse' is 'Yes'.

Provide the spouse's Social Security Number as issued by the Social Security Administration. Fill only if 'Employee’s Spouse' is 'Yes'.

Enter the name of the spouse's current employer or company. Fill only if 'Employee’s Spouse' is 'Yes'.

Enter the spouse employer's full mailing address, including street, city, state and ZIP code as applicable. Fill only if 'Employee’s Spouse' is 'Yes'.

Enter the patient's full name in the order last name, first name, and middle initial as shown on official records.

Provide the patient's date of birth.

Enter the patient's full mailing address, including street, city, state, and ZIP code.

Enter the category that describes the patient (for example: 'Employee', 'Employee's Spouse', 'Employee's Child', or another applicable relationship) to indicate which patient option applies in Section 2.

Check this box when the patient receiving care is the employee (the policyholder); if selected, proceed to Section 3 as instructed.

Check this box when the patient is the employee’s spouse and you will provide the spouse’s information on the form.

Check this box when the patient is the employee’s child and you will provide the child’s (and spouse’s, if required) information on the form.

Enter the date the physician completed and signed this form.

Enter the physician's full printed name as it should appear on the claim.

Enter the physician's professional degree(s) or credential abbreviations (for example MD, DO, PA).

Provide the physician's signature authorizing the accuracy of the information on this form.

Enter the provider's federal Tax Identification Number or Social Security Number used for billing and legal identification.

Check this box if the patient is currently pregnant (and provide the expected date of delivery in the adjacent field if applicable).

Check this box if the patient is not currently pregnant.

Enter the patient’s expected date of delivery if the pregnancy question is answered Yes. Fill only if 'Pregnancy? Yes' is 'Yes'.

Enter the provider's primary telephone number portion (excluding the area code) for contact.

Enter the provider's telephone area code.

Enter the city where the provider's practice or office is located.

Enter the provider's street address, including building number and street name.

Enter the state in which the provider's office is located.

Enter the provider's ZIP or postal code for the street address.

Enter the full name of the physician who referred the patient (last name, first name and middle initial if applicable).

Enter the referring physician's full mailing address including street, city, state and ZIP code.

Enter the name and location (facility name and address) of the facility where the services were rendered, if different from the patient’s home or the provider’s office. Fill only if 'Service Line 1 - Place of Service (POS) Code', 'Service Line 2 - Date of Service (To)', 'Service Line 3 - Date To', 'Service Line 4 - Place of Service' is not '11' or '12' (any).

Enter the procedure code used for this service line (CPT or other procedure code/name as applicable).

Provide a brief description of the surgical or medical services rendered for this service line.

Enter the start date of the service or procedure for this service line.

Enter the Place of Service code that indicates where the services were provided for this service line.

Enter the diagnosis code that corresponds to the condition treated for this service line.

Enter the total charge amount billed for the services rendered on this service line.

Enter the starting date of the service period for this service line.

Enter the place-of-service code or brief name indicating where the service was provided (for example, office, hospital, home).

Provide a concise description of the surgical or medical services performed for this service line.

Enter the ending date of the service period for this service line.

Enter the diagnosis code (for example ICD-10) that corresponds to the service on this line.

Enter the total charge amount billed for the services on this line.

Enter the service start date for this service line.

Enter the place of service code or short label indicating where the service was provided (for example, office, hospital, home).

Provide a concise description of the surgical or medical services rendered for this service line.

Enter the service end date for this service line.

Enter the diagnosis code (ICD-10 or other applicable code) that corresponds to the service provided.

Enter the total charge amount billed for this service line as a numeric value.

Enter the start date when the service(s) for this service line were provided.

Enter the procedure or CPT code used for the service, or the procedure name if a different coding system is being used.

Provide a concise description of the surgical or medical services performed for this service line.

Enter the place of service code or short name indicating where the service was provided (for example, physician's office, inpatient hospital, or patient's home).

Enter the diagnosis code that corresponds to the condition treated for this service line.

Enter the total charge amount billed for the services on this service line.

Enter the date when the patient first received treatment for the illness described, if the claim is for an illness.

Enter the date on which the injury occurred if this claim is for treatment of an injury. Fill only if 'Employment-related injury — Yes' is 'Yes'.

Check this box if the injury or illness described on the form occurred as a result of work or while performing job duties (i.e., it is work-related).

Check this box if the injury or illness described on the form did not occur as a result of work and is not work-related.