MODELO

Accident & Sickness Medical Claim Form

Please mail completed Claim Form with itemized bills and receipts to:
(To expedite your claim, please fax it with readable receipts)

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Claims & Legal Services Phone (301) 680-6865 / (301) 680-6867
Adventist Risk Management Fax (301) 680-6878
12501 Old Columbia Pike E-mail: [email protected]
Silver Spring, MD 20904

Please complete Sections A, B and C. Complete Section D if the claim is for a dependent, other coverage is in effect, or if the claim
is accident related. Complete a separate Claim Form for each individual. Attach bills and/ or receipts and return to the address
listed above. Please note that you may scan and email or fax claims.

SECTION A INSURED / PATIENT INFORMATION SECCIÓN A ASEGURADO / INFORMACIÓN PACIENTE

Name of Group Policy Number
Nombre del Grupo Número de la Póliza
Insured’s Name Insured’s Date of Birth
Nombre del Asegurado Fecha de Nacimiento del Asegurado
Patient’s Name Patient’s Date of Birth
Nombre del Paciente Fecha de Nacimiento del Paciente
Home Address
Dirección
Please provide telephone and facsimile numbers, with country and city codes. teléfono con código de área
Home Phone Number Work Phone Number Fax Number E-mail Address
Teléfono casa Teléfono trabajo correo eletrónico
Manager’s Name Work Phone Number Fax Number E-mail Address
Nombre del gerente Teléfono trabajo correo eletrónico

SECTION B TRAVEL INFORMATION Please complete this section SECCIÓN B INFORMACIÓN DEL VIAJE - completar
My Business location is in (country of employment) Mi local de trabajo es (país que trabajo)

I / we left the above country on (Day / Month / Year) Yo/nosotros salimos del país en (día/mes/año)

I / we visited the following countries Yo/nosotros visitamos los siguientes países

I / we are expected to return home on (Day / Month / Year) Yo/nosotros esperamos regresar en (día/mes/año)

The purpose of my / our trip was El proposito de mi/nuestro viaje fue

SECTION C PAYMENT INFORMATION Please complete Option #1, #2 or #3 SECCIÓN C INFORMACION DE PAGO
OPTION #1 - Payment to INSURED Pago al ASEGURADO por favor, completar 1, ó 2 ó 3
OPCIÓN 1 Please indicate where you wish the payment to be sent and in what currency. Indicar donde desea el pago
Your home address as listed above Direct deposit to your bank account
Su dirección como mencionada Directamente a su cuenta de banco
Name on account: Account #:
Nombre en la cuenta Cuenta
Bank Name: Swift Code:
Nombre del banco Código swift
Bank Address: Currency:
Dirección del banco Moneda
IBAN:

OPTION #2 - Payment to a Provider, e.g. hospital, physician Pago al proveedor - hospital, médico
OPCIÓN 2 Please complete Provider’s name and address in Section E of this Claim Form Más informaciones en
OPTION #3 - Payment to the Employer Pago al empleador sección E de este formulario
OPCIÓN 3
Employer’s Name:
Nombre del empleador

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Employer’s Address:
Dirección del Empleador

Payment Authorization: I authorize payment directly to me, my employer or to the healthcare provider in Section E of this Claim Form.
Autorización de Pago: Yo autorizo el pago directamente a mi empleador or al hospital
INSURED’Sen la Seccion E de este formulario
SIGNATURE FIRMA DEL ASEGURADO DATE FECHA

Patient’s Signature and Release (Parent or Guardian, if claim is for a minor), I certify, to the best of my knowledge, that this Claim Form
does not contain any false, misleading, or incomplete information. I authorize the release of all records or other information which may be
necessary to determine claim payment.

PATIENT’S
SIGNATURE FIRMA DEL PACIENTE DATE FECHA

SECTION D OTHER COVERAGE INFORMATION SECCIÓN D OTRAS INFORMACIONES DE COBERTURA

Complete only if the claim is for a dependent and/or other coverage is in effect or if the claim is accident or work related.
Do you have any other insurance? If yes, please provide source of insurance.
Yes No Tiene otro seguro Si tiene, informar qué seguro
Is this claim accident related? Is this claim worked related? El reclamo está relacionado a trabajo?
El reclamo es por
Yes No Yes No
accidente?
If yes, please provide documents relating to accident or work injury. Si fuera, enviar documentos relacionados.
If claim is due to an accident, are you seeking reimbursement from another source? If yes, please provide source of insurance.
Si el reclamo es por accidente, Yes No busca reembolso de otra fuente? Cual?
Spouse’s name Spouse’s insurance company
Nombre del cónyuge Seguro del cónyuge
Spouse’s employer and telephone #
Teléfono del empleador del cónyuge El dependiente es estudiante tiempo completo?
Dependent’s date of birth Is your dependent a full-time student? Yes No
Fecha nacimiento del dependiente If yes, please provide documentation of current academic registration.
Enviar documentación
SECTION E PHYSICIAN OR PROVIDER Please complete this section. SECCIÓN E MÉDICO O PROVEEDOR
Name of physician or provider Nombre del médico o proveedor de servicio
of service
Address Dirección
Teléfono
Telephone #
Diagnosis or nature of illness or injury Diagnosis o naturaleza de la enfermedad o lesión o daño

Date of illness (first symptom) or injury Date first consulted for this condition
Fecha de la enfermedad o lesión (1ºsintoma) Fecha de la primer consulta - condición
Hospital confinement dates: Date able to return to work
From To
Internacion - fechas Fecha de regreso al trabajo
Total disability dates:Fechas de discapacidad total Partial disability dates: Fechas discapacidad parcial
From To From To
Patient’s account # Cuenta del paciente Amount paid Balance due
Valor pagado Cierre de cuenta
Place of service Diagnosis code and description
Lugar de servicio

Date of Service Procedure code and description/ Predetermination of benefits Charges Total charges
Fecha de Procedimientos y descripción cobros Total cuentas
servicio beneficios

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 AUTORIZACIÓN y DESTINO DE BENEFICIOS
AUTHORIZATION and ASSIGNMENT OF BENEFITS
I, the undersigned authorize any hospital or other medical-care institution, physician or other medical professional, pharmacy, Insurance support
organization, governmental agency, group policyholder, Insurance company, association, employer or benefit plan administrator to furnish to the
Insurance Company named above or its representatives, any and all information with respect to any injury or sickness suffered by, the medical
history of, or any consultation, prescription or treatment provided to, the person whose death, injury, sickness or loss is the basis of claim and copies
of all of that person’s hospital or medical records, including information relating to mental illness and use of drugs and alcohol, to determine
eligibility for benefit payments under the Policy Number identified above. I authorize the policyholder, employer or benefit plan administrator to
provide the Insurance Company named above with financial and employment-related information. I understand that this authorization is valid for
the term of coverage of the Policy identified above and that a copy of this authorization shall be considered as valid as the original.
x I agree that a photographic copy of this Authorization shall be a valid as the original.
x I understand that I or my authorized representative may request a copy of this authorization.
x I understand that I or my authorized representative may revoke this authorization at any time by providing the insurance company
with written notification as to my intent to revoke.
Signature of Insured or Authorized Representative Relationship, If Other Than Dated
Insured Fecha
Firma del asegurado o representante autorizado relacion con asegurado
Address:
Dirección
Fraud Warning: Certain states require specific state mandated fraud language to be included on all claims forms while other states use a
generalized fraud stated. ACE USA Accident &Health has adopted the fraud warning language prescribed by the District of Columbia as its
standard fraud statement. Unless otherwise noted below this statement shall be included on all claims forms, applications and enrollment forms.

District of Columbia Generic Warning:

It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include
imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the
applicant.

The following states have required us to use state specific language as follows:

California
For your protection California law requires the following to appear on this form:
Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and
confinement in state prison.

Colorado
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or
attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages.

Florida
Any person who knowingly and with intent in injure, defraud, or deceive any insurer files a statement of claim or an application containing any false,
incomplete, or misleading information is guilty of a felony of the third degree.

New York
Any person who knowingly and with to defraud any insurance company or other person files an application for insurance or statement of claim
containing any materially false information, or conceals for the purpose of misleading, information concerning any fact thereto, commits a fraudulent
insurance act, which is a crime and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such
violation.

Oklahoma
WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes ant claim for the process of an insurance
policy containing any false, incomplete or misleading information is guilty of a felony.

Pennsylvania
Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially
false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act,
which is a crime and subjects such person to criminal and civil penalties.

Maryland/Oregon
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer submits an application or files a claim containing
a false or deceptive statement may be guilty of insurance fraud.

Virginia
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer submits an application or files a claim containing
a false or deceptive statement may have violated state law.

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