IMG Claim Form
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In order for this form to be a valid proof of claim, you must attach the original documents and make certain that documentation is legible, indicates
patient’s name, date of service, diagnosis, procedure and/or type of service along with the itemized charges.
Failure to submit an accurate, completed form will result in processing delays. The insured has a limited time frame in which to submit a complete
proof of claim, and IMG, at its option, may deny coverage for proof of claim submitted thereafter, for incomplete proof of claim and/or failure to
submit a proof of claim.
Claim Form & Authorization Filing
PART A. To be completed by the claimant for all claims
Claimant/Patient Name:
(As it appears on ID card)
Passport/Visa Number:
Male Female
Date of Birth:
___/___/___ (MM/ DD/YYYY)
Claimant’s Relationship to Primary Insured: Self Spouse Child Other
Name of Primary Insured:
(As it appears on ID card)
Insured ID #:
Male Female
Date of Birth:
___/___/___ (MM/ DD/YYYY)
Home Country Address:
Current Address: City:
State: Postal Code: Home Phone: Work Phone:
Communications should be sent via email to:
Are you a full-time student?
Yes No
Group #:
If yes, please provide the following information:
Name of School:
Street Address: Phone:
City: State: Postal Code: Country:
How many months of the year are you residing in the U.S.?
Street Address: Phone:
City: State: Postal Code: Country:
If claimant is or may be covered by other coverage, complete the items below.
Name of Primary Insured: (as it appears on ID card) Date of Birth: ___/___/___ (MM/ DD/YYYY)
Insured mailing address: City: State: Postal Code:
Name of other carrier: ID # for other coverage:
Type of other coverage: Carrier Phone number:
Carrier address: City: State: Postal Code:
Name of employer: Employer Phone number:
Employer address: City: State: Postal Code:
Please print legibly and complete ALL SECTIONS of this form. Mail, fax, or email completed form to:
Address: International Medical Group, Inc. Claims, P.O. Box 9162, Farmington Hills, MI 48333-9162 USA,
Call: +1.800.628.4664 or outside U.S. +1.317.655.4500; Fax: +1.317.655.4505
IMG Claim Form
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PART B. To be completed by the claimant for each new condition, injury, or illness (if you need additional space, please attach a separate sheet)
1. When did the first symptom of this condition begin? State the exact date if possible: ___/___/___ (MM/ DD/YYYY)
2. How did the condition begin? State fully all symptoms and describe the condition in detail after it began. For accidents, include pertinent details
such as how, when and where the accident occurred.
3. Have you ever had or been treated for this type of condition before? Yes No
4. List all the names and addresses of the providers you have seen for this condition.
5. What sicknesses, diseases, illnesses, injuries, or other physical, medical, mental or nervous disorder, conditions, or ailments have you experienced
during the last five years? Please provide the name and/or description of each condition, dates of treatment, and name and address of the facility
and/or attending physician(s).
6. Is this condition the result of an accident, injury, or illness:
a. Related to employment? Yes No
If yes, are you applying for Worker’s Compensation benefits?
Yes No
b. Involving a motor vehicle or another persons actions? Yes No
If yes, list the names of parties involved, insurance carriers and policy numbers.
c. Was a report filed with any governmental or investigating entities? Yes No
If yes, please identify the department and the address where it was filed.
d. Was this accident related to an organized or sanctioned athletic activity, Yes No
Involving regular or scheduled games and/or practice? If so, was an accident report filed with the sports coordinator? Please provide a copy
of any related accident reports.
e. In the event you have hired legal counsel, please provide IMG with the complete name, address and telephone number of the attorney.
IMG Claim Form
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PART C. Complete for all treatment received outside of the United States.
Date of service
What type of
service and/or
name of drug
What was the
Type of
paid or billed
Total charge
paid or billed
Converted to
U.S. funds
Office use only
Account Holder’s Name:
Bank Name:
Bank Address: City: Country:
Currency of reimbursement: Bank 9 digit ABA number—U.S. banks:
Bank 8 or 11 digit SWIFT code—non-U.S. banks: Sort code:
Bank account number: Bank IBAN:
Intermediary Bank Details (if applicable):
Name of intermediary bank:
Intermediary bank SWIFT code: Intermediary bank account number:
PART D. PAYMENT DETAILS (Checks will only be issued to a United States address.)
Make payment to the provider
Make payment to primary insured
Reimbursement method
Bank ACH or wire transfer (complete below) Check
Make payment to alternate payee
Reimbursement method
Bank ACH or wire transfer (complete below) Check
IMG Claim Form
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If this form is signed by someone other than the patient or parent, such as a personal representative, legal representative or guardian on behalf of the patient, submit the following: a copy of
a healthcare representative form, power of attorney, a court order or other documentation showing custody, or other legal documentation showing the authority of the legal representative
to act on the patient’s behalf.
PART E. AUTHORIZATIONto be completed by the claimant for all claims.
I verify that all information contained in this form is true, correct and complete to the best of my knowledge. I authorize any health plan, health care
provider, health care professional, MIB, federal, state or local government agency, insurance or reinsuring company, consumer reporting agency, employer,
benefit plan, or any other organization or person that has any records or knowledge of my health, has any information available as to diagnosis, treatment
and prognosis with respect to any physical or mental condition and/or treatment of me, and any non-medical information about me, to disclose my entire
medical record, file, history, medications, and any other information concerning me and to give any and all such information to my agent of record and
authorized representatives of Company, IMG, and their affiliates, and subsidiaries. Individuals have the right to refuse to sign the authorization without
negative consequences to treatment or plan enrollment, except IMG will not be able to administer claims, determine benefit eligibility, or issue payments.
The authorization is valid for the term of the insurance contract or plan under which a claim has been submitted.
I understand that I have the right to receive a copy of this authorization upon request and revoke the authorization at any time in a written communication
to IMG. A copy of this shall be as valid as the original. I acknowledge and understand there is the potential for the information to be subject to re-disclosure
by the recipient and to no longer be protected by applicable privacy and confidentiality laws.
Any person who knowingly presents a false or fraudulent claim for payment of a loss of benefit or knowingly presents false information in an
application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Print Name of Insured: X _______________________________________________________________________________________________________
Signature of Insured/Legal Representative: X _______________________________________________________
Date: ___/___/___ (MM/ DD/YYYY)
I authorize payment of any benefits for eligible medical expenses to the provider or other supplier of services which is entitled to payment of the attached bills.
Signature of the Insured/Legal Representative: X ___________________________________________________
Date: ___/___/___ (MM/ DD/YYYY)
Version 0719IN01200799A190731
If needed you can overnight packages to following address:
2960 North Meridian Street, Indianapolis, IN 46208