Fillable Claims Initiation Form

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Claims Initiation Form

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The Claims Initiation Form form is 6 pages long and contains:

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  • 18 check-boxes
  • 207 other fields

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1| Page For assistance, please call 800- 352- 5130
Claims Initiation Form
This form is used to initiate the claims process. Please provide accurate and complete information to the best of your
knowledge and ability. If any assistance is needed in completing this form, our Intake representatives are more than
happy to help. You can reach them at 800-352-5130.
Note: Form completion does not guarantee claim approval and/or benefit reimbursement.
Insured’s Personal Information
Policy Number(s): _____________________________________________________________
Title: Mr. Mrs. Ms.
______________________________ _____ _____________________________________
First Name M.I. Last Name
_____________________________________________________________________________
Address Line 1
_____________________________________________________________________________
Address Line 2
_____________________________________ _________________ __________________
City State ZIP Code
Gender: Male Female Phone Number: ( _____ ) _____ - __________
Date of Birth: _____ / _____ / __________ Current Age: _______
Email Address: _________________________________________________________________
Contact Information
Name of Preferred Contact:
______________________________ _____ _____________________________________
First Name M.I. Last Name
_____________________________________________________________________________
Address
_____________________________________ _________________ __________________
City State ZIP Code
Phone Number: ( _____ ) _____ - __________ Relationship to Insured: _________________
Email Address: ________________________________________________________________
Durable Power of Attorney? Yes No If Yes, please attach POA documentation.
Name: _______________________________
Please note, a Medical POA will not be sufficient.
Is there a Trust in place? Yes No If Yes, please attach Trust documentation.
Name of Trustee: ____________________________
If contact person is other than the insured, please complete the Authorization for Disclosure of Information section on
page 9.
2 | Page For assistance, please call 800- 352- 5130
Insured’s Current Circumstances
Briefly explain why a claim is being filed:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Event(s) (fall, stroke, accident, etc.) including dates:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Surgery: _________________________________________ Date: _____ / _____ / __________
Surgery: _________________________________________ Date: _____ / _____ / __________
Surgery: _________________________________________ Date: _____ / _____ / __________
Are there any limitations to Activities of Daily Living (ADLs)? Yes No
If Yes, mark all that apply:
Bathing Dressing Transferring Eating Toileting Continence
Please provide observations / examples:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Are there any limitations to Instrumental Activities of Daily Living (IADLs)? Yes No
If Yes, mark all that apply:
House cleaning Laundry Shopping Finances Transportation
Meal preparation Medication administration Other: _______________________
Cognitive Status: No noticeable impairment Signs of impairment
If signs of impairment, please list observations / examples:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
List all medical conditions / diagnoses:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
3 | Page For assistance, please call 800- 352- 5130
Hospitalizations
Please provide details regarding any hospital stays relating to the request for claim initiation.
_____________________________________________________________________________
Hospital Name
_____________________________________________________________________________
Address
_____________________________________ _________________ __________________
City State ZIP Code
Phone Number: ( _____ ) _____ - __________ Fax: ( _____ ) _____ - __________
Email Address: ________________________________________________________________
Admit Date: _____ / _____ / __________ Discharge Date: _____ / _____ / __________
_____________________________________________________________________________
Hospital Name
_____________________________________________________________________________
Address
_____________________________________ _________________ __________________
City State ZIP Code
Phone Number: ( _____ ) _____ - __________ Fax: ( _____ ) _____ - __________
Email Address: ________________________________________________________________
Admit Date: _____ / _____ / __________ Discharge Date: _____ / _____ / __________
For additional hospitalizations, please enclose a separate list.
4| Page For assistance, please call 800- 352- 5130
Services
Please provide details regarding any services rendered or anticipated.
Service Type: Nursing Care Facility Assisted Living Facility Home Health Other ________________
Are any Hospice Services included? Yes No
Facility/Agency Name: _________________________________________________________________
Contact Name: _________________________________ Tax ID (if applicable): ____________________
_____________________________________________________________________________
Address
_____________________________________ _________________ __________________
City State ZIP Code
Phone Number: ( _____ ) _____ - __________ Fax: ( _____ ) _____ - __________
Email Address: ________________________________________________________________
Beginning Date of Service : _____ / _____ / __________ Discharge Date (if applicable): _____ / _____ / __________
Serv
ice Type: Nursing Care Facility Assisted Living Facility Home Health Other ________________
Are any Hospice Services included? Yes No
Facility/Agency Name: _________________________________________________________________
Contact Name: _________________________________ Tax ID (if applicable): ____________________
_____________________________________________________________________________
Address
_____________________________________ _________________ __________________
City State ZIP Code
Phone Number: ( _____ ) _____ - __________ Fax: ( _____ ) _____ - __________
Email Address: ________________________________________________________________
Beginning Date of Service : _____ / _____ / __________ Discharge Date (if applicable): _____ / _____ / __________
For additional facilities or services, please enclose a separate list.
5 | Page For assistance, please call 800- 352- 5130
Physician / Provider Information
Please provide the requested information for all physicians (including the insured’s primary care physician) that have
been seen in the past 24 months. The provider may be an individual or an organization. Be sure that information for
each physician/provider is complete and accurate in order to avoid processing delays.
____
__________________________________________________________________________
Name
______________________________________________________________________________
Specialty / Type of Provider
______________________________________________________________________________
Street Address
_____________________________________ _________________ ___________________
City State ZIP Code
Phone Number: ( _____ ) _____ - __________ Fax: ( _____ ) _____ - __________
Email Address: __________________________________________________________________
Date of Last Visit: _____ / _____ / __________
____
__________________________________________________________________________
Name
______________________________________________________________________________
Specialty / Type of Provider
______________________________________________________________________________
Street Address
_____________________________________ _________________ ___________________
City State ZIP Code
Phone Number: ( _____ ) _____ - __________ Fax: ( _____ ) _____ - __________
Email Address: __________________________________________________________________
Date of Last Visit: _____ / _____ / __________
For additional providers, please enclose a separate list.
6| Page For assistance, please call 800- 352- 5130
Agreement and Acknowledgement
I am requesting a determination for benefit eligibility. All of the answers and explanations I have provided are accurate
and complete to the best of my knowledge and ability. I understand that additional information may be considered
(including, but not limited to, onsite assessment(s), plan(s) of care, medical records, physician statements, etc.)
If there are any changes to my health, treatment, or provider, I agree to immediately notify SILAC, in writing (see address
below).
Caution: See the following page for the Fraud Warning applicable in the insured’s state of residence.
Before we can process your claim, you must certify by signing below that the information you have provided on this
form is accurate and complete to the best of your knowledge and ability.
Note: if any form is signed by the Durable Power of Attorney designee, guardian, or executor, please submit the
appropriate documents with this Claims Initiation Form. If the Health Information Authorization is signed by someone
other than the insured, a copy of the Durable Power of Attorney, or guardianship papers, will be required.
Remember to complete and sign:
Health Information Authorization – This form is required to process this claims initiation.
Authorization for Disclosure of Information
Note: With the implementation of the HIPAA privacy rule, our company is restricted from giving out detailed
information regarding your policy or claims to your family members or any other third party, without your authorization.
I, ________________________________, authorize SILAC Insurance Company to release any information regarding my
policy and claims to the following persons:
1. Name:
_____________________________________ Phone Number: ( _____ ) _____ - __________
Relationship: Family POA Guardian Other ___________________
2. Name: _____________________________________ Phone Number: ( _____ ) _____ - __________
Relationship: Family POA Guardian Other ___________________
By checking this box, I certify that this shall be considered an effective and binding signature.
Date: _____ / _____ / __________
Printed Name (insured or Legal Representative): __________________________________________
Return your completed form(s) to:
SILAC Insurance Company; Attn: LTC Claims Department
| P.O. Box 30245, Salt Lake City, UT 84110 | 299 S. Main Street, Ste 1100, Salt Lake City, UT 84111 | Fax: 801-579-3715 |
7 | Page For assistance, please call 800- 352- 5130
Fraud Statements
AZ residents: For your protection Arizona law requires the
following statement to appear on this form. Any person who
knowingly presents a false or fraudulent claim for payment of a loss
is subject to criminal and civil penalties.
AL residents: Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benefit or who knowingly
presents false information in an application for insurance is guilty
of a crime and may be subject to restitution fines or confinement in
prison, or any combination thereof.
AR / LA and RI residents: Any person who knowingly presents a
false or fraudulent claim for payment of a loss or 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.
CO residents: 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. Any insurance company or agent of an insurance
company who knowingly provides false, incomplete, or misleading
facts or information to a policyholder or claimant for the purpose of
defrauding or attempting to defraud the policyholder or claimant
with regard to a settlement or award payable from insurance
proceeds shall be reported to the Colorado division of insurance
within the department of regulatory agencies.
DE residents: A person who knowingly and with intent to injure,
defraud, or deceive any insurer, files a statement of claim
containing any false, incomplete, or misleading information is guilty
of a felony.
ID residents: Any person who knowingly and with intent to defraud
or deceive any insurance company, files a statement of claim
containing any false, incomplete, or misleading information is guilty
of a felony.
IN residents: A person who knowingly and with intent to defraud
an insurer files a statement of claim containing any false,
incomplete, or misleading information commits a felony.
KY residents: 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.
MD residents: Any person who knowingly or willfully presents a
false or fraudulent claim for payment of a loss or benefit or who
knowingly or willfully presents false information in an application for
insurance is guilty of a crime and may be subject to fines and
confinement in prison.
ME / TN / VA and WA residents: It is a crime to knowingly provide
false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties
include imprisonment, fines and denial of insurance benefits.
NH residents: Any person who, with the purpose to injure, defraud
or deceive any insurance company, files a statement of claim
containing any false, incomplete or misleading information is
subject to prosecution and punishment for insurance fraud, as
provided in N.H. Rev. Stat. Ann. 638:20.
NM residents: Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty
of a crime and may be subject to civil fines and criminal penalties.
OH residents: 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
is guilty of insurance fraud.
OK residents: Warning: Any person who knowingly, and with
intent to injure, defraud or deceive any insurer, makes any claim
for the proceeds of an insurance policy containing any false,
incomplete or misleading information is guilty of a felony.
PA residents: Any person who knowingly and with intent 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 material thereto commits a fraudulent
insurance act, which is a crime and subjects such person to
criminal and civil penalties.
TX residents: Any person who knowingly presents a false or
fraudulent claim for payment of a loss is guilty of a crime and may
be subject to fines and confinement in state prison.
WV residents: Any person who knowingly presents a false or
fraudulent claim for payment of a loss or 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.
All other states residents: Any person who knowingly and with
intent to defraud any insurance company that submits an
application for insurance or statement of claim containing any
materially false information, or conceals information concerning
any fact material thereto for the purpose of misleading, may be
committing a crime which is subject to criminal and civil penalties.
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Claims Initiation Form

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Completed 23 March 2021

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