FIRST STUDENT
P.O. BOX 809025
DALLAS, TEXAS 75380-9025
Coverage Verified
NOTICE: Anyone who knowingly misrepresents or falsifies essential information requested
by this form may, upon conviction, be subject to fine or imprisonment.
❑ GRADUATE
-PLEASE PRINT ALL INFORMATION-
❑ UNDERGRADUATE
PART I - MUST BE COMPLETED BY STUDENT AND SIGNED
Name of College or University, City and State
Domestic ❑
Student ID Number
Birth Date
International ❑
Insured Student’s Name
LAST NAME FIRST NAME M.I. SOCIAL SECURITY # PHONE #
❑Present Address
Street Address
❑Home Address
City
State
Zip
PLEASE MAIL ALL CORRESPONDENCE AND PAYMENTS TO THE ADDRESS ABOVE.
If claim for dependent, give dependent’s name
Relationship to Insured
Age
Sex
1. Date of accident or sickness.
Date of first treatment
2. Indicate reason for medical treatment.
3. If injury, describe how and when accident
occurred and indicate if work related.
❑Intramural
❑Club
4. If injured in play or practice of sport,
Check
❑Intercollegiate
indicate which sport.
One
❑Other
5. Have you previously been troubled
❑ Yes
with this condition?
❑ No Date
6. Were you seen or referred by the
❑ Yes
physician for this condition?
❑ No Date
7. Name and address of Provider,
other than Student Health Service.
8. Give names of all other physicians
consulted.
From:
9. Hospitalized? If so where and what dates.
Where?
To:
PAYMENT WILL BE MADE TO THE PROVIDERS OF SERVICE, UNLESS A PAID RECEIPT IS ATTACHED AT TIME OF SUBMISSION.
To any medical care provider, medical care facility, insurer, government-sponsored health plan, or employer: I authorize the release of any medical information about me
to Student Insurance. This applies to all information about the diagnosis, treatment, or prognosis of any illness or injury I now have or have had in the past. The Company
will use this information to determine if my claim is eligible. Any information obtained will not be released by the Company except to my primary health insurance car-
rier (if any) or persons or organizations performing investigative or legal services for the Company in connection with my claim. A copy of this authorization shall be
considered as effective and valid as the original and shall remain in effect for one year from the date of authorization. I certify that the information given by me in sup-
port of my claim is true and correct.
Patient’s or Authorized Representative’s Signature
Date
If Authorized Representative, Relationship to Patient
or Legal Designation
STREET CITY STATE ZIP CODE + 4
ITEMIZED BILLS FOR MEDICAL EXPENSES MUST BE ATTACHED.
0000-CLM
CLAIM FORM
COMPLETE IN DETAIL
TO INSURE
PROMPT HANDLING
Mother’s Name
Employer
Name and Address of Insurance Co.
Policy No.
Father’s Name
Employer
Name and Address of Insurance Co.
Policy No.
Spouse’s Name
Employer
Name and Address of Insurance Co.
Policy No.
Are you covered (as an insured or dependent) by any other hospital and/or medical plan?
❑Yes
❑No
Have you filed a claim with any other insurance company?
❑Yes
❑No
Send copies of all Explanation of Benefits paid or denied to First Student at the above address.
MUST BE COMPLETED
PART II - ATTENDING PHYSICIAN STATEMENT
This Statement MUST Be Completed
AUTHORIZATION:
I hereby authorize The Chesapeake Life Insurance Company, to inspect or secure copies of case
history records, laboratory reports, diagnoses, prognoses, and any other data covering this or other
confinements disabilities.
DOCTOR, PLEASE SIGN
DATE
EACH DOCTOR’S BILL ATTACHED NEEDS TO BE COMPLETED WHEN ITEMIZED WITH THE DOCTOR’S I.D. OR SOCIAL SECURITY NUMBER
Patient’s name
Date of Birth
1. Nature of sickness or injury
Describe any complications. (Include ICD-9)
2. If fracture or dislocation, state whether
reduced or immobilized. If fracture of
long bones, state whether fracture is
through shaft or extremity. Was it
confirmed by X-Ray?
❑ No ❑ Yes
3. When did symptoms first appear or
accident happen?
Date
4. When did patient first consult you for this
condition?
Date
5. Has patient ever had same or similar
condition? If yes, state when and describe.
❑ No ❑ Yes When?
Date
6. Describe any other disease or infirmity
affecting present condition.
7. Nature of any surgical or obstetrical
procedure. Describe fully.
(Include CPT Code)
Where and when performed?
Date
if in hospital, inpatient ❑
outpatient ❑
8. Give dates of treatment.
9. Is condition a result of or in any way
connected with pregnancy?
❑ No ❑ Yes Inception date of pregnancy
10. Is patient still under your care for this
condition? If discharged, give date.
❑ No ❑ Yes When?
Date
11. If patient hospitalized, give name and
and address of hospital.
Hospital City State
Date admitted
Date discharged
12. Did you file this claim with any other
❑ No ❑ Yes
Name:
Insurance Company? If yes, indicate
the name and address of company.
Address:
SIGNED:
DEGREE
DATE
I.D. or S.S. #
(THIS MUST BE INCLUDED!) PHONE#
ADDRESS:
STREET CITY STATE ZIP CODE + 4
IF DENTISTRY, ANSWER ALL QUESTIONS BELOW, IN ADDITION TO THOSE ABOVE.
1.
State exactly which teeth were involved in the accident and indicate them
on chart.
2.
Describe exact nature of injury.
3.
Describe condition of injured teeth prior to accident:
❑Whole, sound and natural ❑Filled ❑Crowned ❑Artificial
4.
Comments:
IMPORTANT: This form MUST be completed and returned WITHIN 30 DAYS from the date of treatment accompanied by all bills incurred by that date.
