Fillable Facility Claim Form This form is for the

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Facility Claim Form This form is for the

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Fo r a s s i s ta nce, pl ea s e c a l l 8 0 0 - 352- 5150
Facility Claim Form
This form is for the purpose of filing for reimbursement of charges for facility care. This form can be completed by either
the insured, their Legal Representative, or the facility’s business office manager after the end of each month. This form is
not applicable for Home Care claims.
Note: The corresponding facility invoice must be attached with this form to ensure accurate and timely processing of
this claim.
_________________________________________________ _______________________________________
Insured’s Name (please print) Policy Number(s)
_________________________________________________ _______________________________________
Facility Name Facility Type
___________________________________________________________________________________________
Address
__________________________________________ ______________________ ___________________
City State ZIP Code
_____________________________________ ( _____ ) _____ - __________ ( _____ ) _____ - __________
Contact Name Phone Number Fax Number
Email Address: _______________________________________________________________________________
Claim Information
1. Dates of Service: From: _____ / _____ / __________ To: _____ / _____ / __________
2. During this claim, did the insured spend more than 24 hours physically out of the facility? Yes No
a. If yes, please mark reason: Hospitalization Rehab Time with family Other: ____________
i. Name of Hospital (if applicable): _______________________________________________
b. List dates: From: _____ / _____ / __________ To: _____ / _____ / __________
c. If there were any bed hold or reservation charges, please provide daily amount: $_____________
3. During this claim, were any days paid in full by Medicare or Medicare Advantage? Yes No
a. If yes, please list dates: From: _____ / _____ / __________ To: _____ / _____ / __________
4. During this claim, did Medicare or Medicare Advantage charge any coinsurance? Yes No
a. If yes, please list dates: From: _____ / _____ / __________ To: _____ / _____ / __________
b. Daily amount of coinsurance or co-payment required: $_____________
Insured’s Status
During this claim, have there been any changes to the insured’s health status, level of care, or change in facility?
Yes No If Yes, please provide details: ___________________________________________________
_________________________________________________________________________________________
Please provide deceased date if applicable: _____ / _____ / __________
Facility Information
2 | Page
Completed Services
1. Special Rehabilitation Therapy: Physical Therapy Speech Therapy Occupational Therapy
Performed by or under the Supervision of a qualified Physical Therapist, Occupational Therapist or Speech Therapist.
Please indicate need, type and frequency. Also include copies of therapy notes and charts.
______________________________________________________________________________________________
______________________________________________________________________________________________
2. Please indicate which level of service was provided for which dates during this claim:
Custodial Care: from _____ / _____ / __________ to _____ / _____ / __________
Intermediate Care: from _____ / _____ / __________ to _____ / _____ / __________
Skilled Care: from _____ / _____ / __________ to _____ / _____ / __________
Custodial Care is primarily for the purpose of meeting personal needs and involves primarily personal care services;
such as administration of routine oral medications, eye drops and ointments.
Intermediate Care is performed under the direction and supervision of a Licensed Registered Nurse (LPN) with care
provided by an RN or LPN for a minimum of six (6) hours weekly.
Skilled Care is performed under the direction and supervision of a Licensed Registered Nurse (LPN) with care provided
by an RN or LPN on a daily basis following an inpatient hospital stay of 3 days or longer.
Contact Information & Agreement
This form was completed by (printed name): ____________________________ Relationship: _____________________
(
_____ ) _____ - __________ ( _____ ) _____ - __________ ____________________________________________
Phone Number Fax Number Email Address
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit is guilty of a
crime and may be subject to fines and confinement in prison.
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) and the corresponding invoice(s) to:
SILAC Insurance Company; Attn: LTC Claims Department
| P.O. Box 2460, Salt Lake City, UT 84110 | 299 S. Main Street, Ste 1100, Salt Lake City, UT 84111 | Fax: 801-579-3715 |
Fo r a s s i s ta nce, pl ea s e c a l l 8 0 0 - 352- 5150
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Completed 23 March 2021

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