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.
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,
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.