P.O. Box 4786
Missoula, MT 59806-3018
Fax 406-523-3143
1C. Patient's date of birth 1D. Patient's sex
Female___ Male___
1E. Name of participant (First, middle initial, last)
1F. Participant's date of birth 1G. Patient's relationship
to participant
MM/DD/YY Self___ Spouse___ Child___
2E. Policy or identification number of other coverage
2H. Date of birth
4A. Type of 4D. Dates of service or 4E. Charges
provider purchase
2F. Type of coverage: Medical: Yes___ No___ 2G. Name of participant
Dental: Yes___ No___ Vision: Yes___ No___ Rx: Yes___ No___
2A. Name and address of insuring company
1. Patient Information 1A. Identification number
1B. Patient's name (First, middle, last)
2D. Termination date
1H. Participant's current mailing address (Street, city, state, and country or ZIP code)
2. Other Health Insurance -
Is the patient covered under other health insurance, including Medicare A or B?
Yes___ No___ If yes, complete 2A through 2K below.
2B. Type of policy
Family___ Individual___
2C. Effective date
2K. If patient is covered under Medicare, complete the following: Medicare Part A: Yes___ No___ Medicare Part B: Yes___ No___
2I. Employer of participant
2J. Employment status
Active employee___ Retired employee___ COBRA___
Effective date: _____________ Effective date: ____________
3. Diagnosis 3A. Describe illness, injury, or symptoms requiring treatment 3B. Was patient's treatment due to a work-related
accident or condition? Yes___ No___
3C. Complete for care related to accidental injuries
Date of accident ___________________________ Location: At home___ Auto___ Other _________________________________
5. Signature -
I verify the above is complete and correct and that I am claiming benefits only for charges incurred by the patient named
above. Authorization is hereby given to any provider of service, which participated in any way in the patient's care, to release to
the participant's Plan any medical information which they deem necessary to adjudicate this claim.
Signature of participant or patient _____________________________________________ Date ______________________
If the accident was caused by someone else attach a statement describing the accident.
4. Charges - Use a separate line to list each type of service or provider and attach itemized bills for all the services.
4B. Name of provider
making charges
4C. Description of service
Domestic and International Claim Form Instructions
Please complete all items on the claim form. If the information requested does not apply to the patient, indicate N/A
(Not Applicable). Special care should be taken when completing the following items:
2. Other Health Insurance
If the patient holds other insurance coverage, please complete items A through K as completely as possible. It is
especially important to indicate the name and address of the other insurance company and the policy or
identification number of that coverage, as well as the name and birth date of the person who holds that policy.
In addition, if the patient is someone other than the subscriber and has received benefits from any other health
insurance plan held by reason of law or employment, the Explanation of Benefits Form furnished by the other carrier
pertaining to these charges must be included with the claim. A Clear photocopy of the other carrier’s Explanation of
Benefits Form is acceptable in place of the original document.
4. Charges
Please list here the bills that are being included o this claim. Although itemized bills must also be submitted, your
listing will enable us to process the claim more quickly and accurately. If additional space is needed for listing
charges, please use a separate sheet of paper to list the following information.
4A. Type of provider - for example: hospital, nurse, physician, clinic, physical therapist, etc.
4B. Name of provider - as indicated on the bill. Multiple bills from the same provider may be included on the
same line, as long as they are for the same type of service.
4C. Description of service - for example: hospital admission, office visit, chest x-ray, lipid levels, appendectomy,
acupuncture, etc.
4D. Date of service or purchase inclusive dates may be indicated for bills containing multiple dates of service.
4E. Charge bills must be itemized to show a separate charge for each service. If the bill has already been paid,
please indicate the date it was paid. Charges must be listed in U.S. currency.
5. Signature The International Claim Form must be signed and dated by the participant, spouse, or the patient.
Itemized Bill Information
Each provider’s original itemized bill must be attached and must contain:
- The letterhead indicating the name and address of the person or organization providing the service
- The full name of the patient receiving the service
- The date of each service
- A description of each service
- The charge for each service
This completed claim form together with itemized bills and supporting documentation, should be submitted to:
Allegiance Benefit Plan Management
P.O. Box 4786
Missoula, MT 59806-3018
Claims in foreign language or currency must be translated into English and United States currency.