Fillable Form 104280-C09 CICA combinedinsurance.com

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Form 104280-C09 CICA combinedinsurance.com

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C-CLMS-FRM-1-0518
FILING A CLAIM BY MAIL
1. Download the claim form
2. Print all six pages of the claim form
3. Complete the first page of the claim form including Section B or C and
Sections D and E.
4. Sign and date the first page. There are two areas for your signature marked
with an “X” at the bottom of the first page
5. Have your doctor complete the Attending Physician’s Statement on the
second page.
6. If you are claiming disability, have your employer complete the Employer’s
Statement found at the top of the second page.
7. Sign and date the Fraud Notification on page 5 of the claim form.
8. Send your signed completed claim form with the Physicians Statement, Employer
Statement if applicable, and any medical bills or reports that you may have related
to your accident or illness to:
Combined Insurance Claim Department
PO Box 6700
Scranton, PA 48585-0700
Claims Made Easy
For faster claim payment* please submit your claim
online at www.CombinedInsurance.com/Claims
* on average claims submitted online receive claim payments faster
Combined Insurance Company of America | Chicago, IL
In New York: Combined Life Insurance Company of New York | Latham, NY
Claims Made Easy
HELPFUL TIPS:
First page (Claimant completes)
Please include your complete name and current mailing address on the claim form as any
payment and / or correspondence will be sent to the address indicated on the claim form.
Indicate your policy numbers on the claim form; this will help us respond quicker.
Second page (Employer and Doctor complete)
If you are employed outside the home, your employer must verify your disability by
completing Section F – Employer’s Statement. If the insured is a student, the school
principal should complete this section.
The primary physician must complete Section G – Attending Physician’s Statement in its
entirety including the diagnosis, a description of how the condition originated and dates
of treatment. If your claim involves disability and / or hospital confinement, these dates
must also be included by your physician. Failure to make sure that your physician fills in all
necessary information on the claim form may cause delays in the processing of your claim.
For your records, we suggest that you keep a copy of the completed claim form and any
bills you submit. Note the date mailed. Mail both pages of the completed form and any
enclosures to:
Combined Insurance Claims Department
P O Box 6700, Scranton, PA 18505-0700
* On average
Remember, you get paid 10 days faster* when you submit a claim online at
www.CombinedInsurance.com/Claims
Accident: For loss due to an accidental bodily injury, please complete the Accident
section of the form including a detailed description of how the accident occurred.
Sickness: If filing for loss due to sickness, fill in the section of the form relating to
symptoms and diagnosis.
Hospitalization: If hospitalized, provide us with the name and address of the hospital
including the admission and discharge dates. Please also send a copy of the itemized
hospital bill including the number of days you were an inpatient.
Disability: If you were disabled and have disability coverage, give the exact dates of
total and/or partial disability. If you are still disabled at the time you submit the form,
another form will be sent to you for continuing disability.
Additional: Please be sure to sign and date the Authorization to Release Information
located near the bottom of the form. This will prevent unnecessary delays in the event
additional information is needed.
Combined Insurance Company of America | Chicago, IL
In New York: Combined Life Insurance Company of New York | Latham, NY
COMBINED INSURANCE COMPANY OF AMERICA
Claim Department • P.O. Box 6700 • Scranton, PA 18505-0700 Telephone 1-800-225-4500 Fax 312-351-6930
IMPORTANT INSTRUCTIONS FOR FILING CLAIM
1. ONLY THIS ONE FORM IS NECESSARY FOR ALL POLICIES.
2. IF DISABILITY IS CLAIMED, PLEASE HAVE YOUR EMPLOYER OR
SCHOOL COMPLETE STATEMENT ON REVERSE SIDE.
3. IF MEDICAL OR HOSPITAL BENEFITS ARE CLAIMED, ITEMIZED BILLS
MUST BE ATTACHED.
IF CLAIM IS FOR
SICKNESS
PLEASE
COMPLETE
Section B
PLEASE COMPLETE
FOR BOTH
ACCIDENT
AND
SICKNESS
CLAIMS
IF CLAIM IS FOR
ACCIDENT
PLEASE
COMPLETE
Section C
Section D
Section E
AUTHORIZATION TO RELEASE INFORMATION
Section A
PLEASE PRINT—DO NOT WRITE
CLAIMANT’S FULL NAME
MR.
MRS.
MISS
SOCIAL SECURITY # (LAST 4 DIGITS) E-MAIL ADDRESS
PLEASE LIST OTHER NAMES THAT YOU MAY USE SUCH AS MAIDEN NAME, NICKNAME, ETC. AREA CODE HOME PHONE BUSINESS PHONE
MAILING ADDRESS (City) (State) (Zip)
MO. DAY YR.
BIRTH
DATE
/ /
Is claimant eligible for Medicaid or a similar state program?
씲 YES NO 씲
HEIGHT WEIGHT
POLICY NUMBER(S)
a)
FORM NUMBER(S)
a)
LAST PAYMENT DATE
MO. DAY YR.
a)
/ /
b)
NAME OF OTHER INSURANCE CARRIER
b)
b)
/ /
OCCUPATION DATE LAST WORKED MONTHLY EARNINGS
ARE YOU FILING CLAIM UNDER WORKERS’ COMP. ACT?
씲
YES NO
씲
EMPLOYER’S NAME AND ADDRESS
DATE OF FIRST SYMPTOMS
MO. DAY YR.
/ /
DATE OF ACCIDENT
MO. DAY YR.
/ /
PLEASE STATE EXACTLY WHERE YOU WERE WHEN ACCIDENT OCCURRED INCLUDING A DETAILED DESCRIPTION OF HOW ACCIDENT OCCURRED.
HOSPITAL’S NAME AND ADDRESS AND TELEPHONE # AND CONFINEMENT DATES
ATTENDING PHYSICIANS’ NAMES AND ADDRESSES DATES OF TREATMENT
TIME OF ACCIDENT
. . . . . AM . . . . . PM
NATURE OF INJURIES
NATURE OF SICKNESS
HAVE YOU EVER HAD SAME OR SIMILAR CONDITION?
씲
YES NO
씲
MO. DAY YR.
IF YES, GIVE DATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . / /
MO. DAY YR.
TO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . / /
MO. DAY YR.
FROM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . / /
MO. DAY YR.
THROUGH. . . . . . . . . . . . . . . . . . . . . . . . . / /
MO. DAY YR.
A) FROM . . . . . . . . . . . . . . . . . . . . . . . . . . . / /
ARE YOU RECEIVING SSDI?
씲 YES NO 씲
ARE YOU RECEIVING STATE
DISABILITY BENEFITS?
씲 YES NO 씲
A) TOTAL DISABILITY: BETWEEN WHAT DATES WERE
YOU UNABLE TO PERFORM ANY DUTIES?
THROUGH. . . . . . . . . . . . . . . . . . . . . . . . . / /C) FROM . . . . . . . . . . . . . . . . . . . . . . . . . . . / /
C) PARTIAL DISABILITY: BETWEEN WHAT DATES WERE
YOU ABLE TO PERFORM ONLY PARTIAL DUTIES?
B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
/ /
B) DATE RETURNED TO WORK
WOULD IT BE ALL RIGHT IF, DURING THE NEXT YEAR, WE MENTION YOUR CLAIM BENEFITS WHEN TALKING TO PROSPECTIVE POLICYHOLDERS ABOUT OUR CLAIM SERVICE?
씲
YES NO
씲
IF YOU WISH TO DISCONTINUE THIS AUTHORIZATION AT ANY TIME, PLEASE CALL US AT 1-800-225-4500. THANK YOU.
MO. DAY YR.
DATED: . . . . . . . . . . . . . . . . . . . . . . . . . . . / / SIGNED: X . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CLAIMANT’S SIGNATURE (If Minor, Parent’s Signature)
MO. DAY YR.
DATED: . . . . . . . . . . . . . . . . . . . . . . . . . . . / /
SIGNED: X . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CLAIMANT’S SIGNATURE (If Minor, Parent’s Signature)
104280-C 104280-C-09
I authorize any hospital, medical practitioner, medically related facility, prescription drug database, insurance company, state and federal government
agency, the Internal Revenue Service, employer, consumer reporting agency or the MIB (Medical Information Bureau) to release to Combined
Insurance Company of America any information for the purpose of processing a claim. Combined is also authorized to disclose such information to
any doctor. This authorization or photocopy shall be valid for the duration of the claim. A copy is available upon request.
THE STATEMENTS MADE BY ME ON THIS CLAIM FORM ARE TRUE AND COMPLETE. I HAVE READ AND UNDERSTAND THE FRAUD LANGUAGE SPECIFIC TO MY STATE, IF ANY,
APPEARING ON THE ATTACHED FRAUD NOTIFICATIONS PAGES. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURANCE COMPANY
FILES A STATEMENT OF CLAIM OR APPLICATION CONTAINING ANY FALSE, INCORRECT OR MISLEADING INFORMATION IS GUILY OF A FELONY OF THE THIRD DEGREE.
EMPLOYER’S STATEMENT (IF STUDENT, PLEASE HAVE SCHOOL PRINCIPAL COMPLETE)
ATTENDING PHYSICIAN’S STATEMENT
Section F
Section G
EMPLOYEE’S NAME
IF SELF-EMPLOYED, PROVIDE A BRIEF DESCRIPTION OF PRIMARY DUTIES.
TOTAL DISABILITY: BETWEEN WHAT DATES WAS THE
EMPLOYEE UNABLE TO PERFORM THEIR DUTIES?
NAME AND ADDRESS OF COMPENSATION CARRIER
WORKERS’ COMP. CLAIM FILED
FOR THIS DISABILITY?
씲
YES NO
씲
MO. DAY YR.
TO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . / /
MO. DAY YR.
FROM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . / /
PARTIAL DISABILITY: BETWEEN WHAT DATES DID
EMPLOYEE PERFORM ONLY PART OF DUTIES?
DATE LAST WORKED
DATE TITLE SIGNATURE
PATIENT’S NAME ADDRESS CITY-STATE-ZIP CODE AGE
씲 SICKNESS
1. NATURE AND ORIGIN OF:
씲 INJURY
2. WHEN DID SYMPTOMS FIRST APPEAR OR
ACCIDENT HAPPEN?
DIAGNOSIS (DESCRIBE COMPLICATIONS, IF ANY)
CONFIRMED BY X-RAY?
씲 YES NO 씲
TELEPHONE
MONTHLY EARNINGS
MO. DAY YR.
TO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . / /
MO. DAY YR.
FROM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . / /
MO. DAY YR.
DATE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . / /
3. WHEN DID PATIENT FIRST CONSULT YOU
FOR THIS CONDITION?
6. DESCRIBE ANY OTHER DISEASE OR INFIRMITY
AFFECTING PRESENT CONDITION.
7. NATURE OF SURGICAL OR OBSTETRICAL
PROCEDURE, IF ANY. (DESCRIBE FULLY AND
GIVE APPROACH USED IF MORE THAN ONE
IS POSSIBLE.)
8. GIVE DATES OF TREATMENT, AND NATURE
OF TREATMENT OTHER THAN SURGICAL.
9. IS PATIENT STILL UNDER YOUR CARE FOR
THIS CONDITION? IF DISCHARGED, GIVE DATE,
AND DEGREE OF RECOVERY.
10. IF HOSPITALIZED, GIVE NAME AND ADDRESS
OF HOSPITAL AND DATES OF CONFINEMENT.
11. HOW LONG WAS OR WILL PATIENT BE CONTINUOUSLY
TOTALLY DISABLED (UNABLE TO WORK)?
4. HOW DID CONDITION ORIGINATE?
5. HAS PATIENT EVER HAD SAME OR SIMILAR
CONDITION? (IF “YES”, STATE WHEN AND
DESCRIBE.)
MO. DAY YR.
DATE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . / /
DATE RETURNED TO WORK
(OR SCHOOL)
MO. DAY YR.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
/ /
씲 YES NO 씲
MO. DAY YR.
DATES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . / /
APPROACH USED. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DATES:
OFFICE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HOME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HOSPITAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NATURE OF TREATMENT
CLOSED REDUCTION? . . . . . . . . . . . . .
OPEN REDUCTION? . . . . . . . . . . . . . . .
METAL FIXATION? . . . . . . . . . . . . . . . . .
씲 YES NO 씲
MO. DAY YR.
DATE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . / /
RECOVERED?
씲 YES NO 씲
MO. DAY YR.
FROM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . / /
MO. DAY YR.
TO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . / /
MO. DAY YR.
FROM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . / /
MO. DAY YR.
THROUGH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . / /
12. HOW LONG WAS OR WILL PATIENT BE
PARTIALLY DISABLED?
13. IF PATIENT DISABLED ON DATE YOU COMPLETE THIS
FORM, IS THERE A RETURN TO WORK DATE?
(IF “YES”, GIVE RETURN TO WORK DATE.)
MO. DAY YR.
FROM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . / /
MO. DAY YR.
THROUGH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . / /
MO. DAY YR.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . / /
HOSPITAL CITY STATE
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
씲 YES NO 씲
RETURN TO WORK DATE:
PHYSICIAN’S NAME SIGNATURE DEGREE
COMPLETE ADDRESS
DATE TELEPHONE
MUST BE FURNISHED UNDER AUTHORITY OF SECTION 6109 OF THE IRS CODE
INDIVIDUAL PRACTITIONER’S S.S. NO. ALL OTHERS - EMPLOYER I.D. NO.
104280-C
Combined Insurance Company of America
C
laim Department • PO Box 6700 • Scranton, PA 18505-0700 Telephone 1-800-225-4500 Fax 312-351-6930
FRAUD NOTIFICATIONS
If you are a resident of or if the policy was issued in one of the following states, we are required to provide you
with the following Fraud Warning Notification:
ALABAMA
: 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.
ALASKA: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim
containing false, incomplete, or misleading information may be prosecuted under state law.
ARIZONA: 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.
ARKANSAS: 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.
CALIFORNIA: For your protection California law requires the following to appear on this form: Any person who
knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to
fines and confinement in state prison.
COLORADO: 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.
DELAWARE:
Any 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.
DISTRICT OF COLUMBIA: WARNING: It is a crime to provide false or misleading information to an insurer for the
purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an
insurer may deny insurance benefits, if false information materially related to a claim was provided by the Applicant.
FLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of
claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third
degree.
IDAHO: 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.
INDIANA: A person who knowingly and with the intent to defraud an insurer files a statement of claim containing
any false, incomplete, or misleading information commits a felony.
KENTUCKY: 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.
LOUISIANA:
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.
MAINE: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for
the purpose of defrauding the Company. Penalties may include imprisonment, fines or a denial of insurance
benefits.
MARYLAND:
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.
MINNESOTA: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty
of a crime.
NEW HAMPSHIRE: Any person who, with a 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 RSA 638:20.
NEW JERSEY: Any person who knowingly files a statement of claim containing any false or misleading information
is subject to criminal and civil penalties.
NEW MEXICO: 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.
FRAUD NOTIFICATIONS CONTINUED
NEW YORK: 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the
claim for each such violation.
OHIO: 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.
OKLAHOMA: 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.
PENNSYLVANIA: 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.
PUERTO RICO: Any person who knowingly and with the intention of defrauding presents false information in an
insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss
or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon
conviction, shall be sanctioned for each violation with the penalty of a fine of not less than five thousand ($5,000)
and not more than ten thousand ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties.
Should aggravating circumstances be present, the penalty thus established may be increased to a maximum of five
(5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.
RHODE ISLAND: 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.
TENNESSEE: 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.
TEXAS: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a
crime and may be subject to fines and confinement in state prison.
VIRGINIA: 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.
WASHINGTON: 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.
WEST VIRGINIA: 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: Any person who knowingly and with intent to defraud any insurance company or other
persons, 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,
subject to criminal prosecution and/or civil penalties.
REQUIRED SIGNATURE OF CLAIMANT
By making claim to these proceeds, I declare that all the answers recorded on this statement are true and complete
to the best of my knowledge and belief. I have read the applicable fraud notification statement. I also understand
the Company reserves the right to require or obtain further information, should it be deemed necessary.
If your policy/certificate is paid with pre-tax dollars, benefits paid may be reported to the IRS. Contact your
employer regarding reporting requirements.
X _________________________________________ ______________ __________________________________
CLAIMANT’S SIGNATURE DATED PLEASE PRINT NAME
I signed on behalf of the claimant, as ________________________________ (relationship). If you are the Power of
Attorney, Guardian or Conservator, please attach a copy of the document granting authority.
AUTHORIZATION TO DISCLOSE HEALTH INFORMATION
Claim or Policy Number: __________________________________________________________________
Name: _____________________________________ Doctor’s Name: ______________________________
Address: ___________________________________ Hospital’s Name: _____________________________
Birthdate: _____ /_____ /_____ Adm. ____ /____ /____ Disch. ____ /____ /____
This will authorize COMBINED INSURANCE COMPANY OF AMERICA, PO BOX 6700, Scranton, PA, 18505-0700 to
obtain necessary medical information for the purposes of evaluating my insurance claim. The information to be
obtained shall include information from any Prescription Drug Database, all health care providers, employer, consumer
reporting agency, any other insurance company, or the “MIB” (Medical Information Bureau), which is relevant to my
loss or condition being evaluated.
The information to be disclosed may include but is not limited to:
History of Present Illness Consultant’s Report Discharge Summary
Operative Reports Pathology Reports Laboratory Results
Daily Doctor’s Notes Past Medical History Previous Admissions
X-Ray Reports Blood/Toxicology
The information is needed for the following purpose(s):
Evaluation and processing of my insurance claim
I understand that the information released by this authorization may also include information concerning treatment
of physical and mental illness, HIV, alcohol/drug abuse and past medical history.
I understand upon fulfillment of the above stated purposes, this consent will automatically expire (6) months following
date of signature without any express revocation. I understand and I have the right to revoke this authorization at any
time, and in order to do so, I must present a written revocation to Combined Insurance Company of America.
I understand that revocation will not apply to my insurance company when the law provides my insurer with the
right to contest a claim under my policy/certificate or evaluate my insurance application for coverage.
Federal and state laws protect the information disclosed pursuant to this authorization. I understand that any
disclosure of information carries with it the potential for re-disclosure and the information may not be protected by
the federal confidentiality rules. Treatment, payment, enrollment or eligibility of benefits may not be conditioned on
obtaining the individual’s authorization.
X
______________________________________________
Date:
_______________________________________
(Signature of Claimant) (Must be filled in)
X
______________________________________________ ___________________________________________
(Signature of Parent or Guardian) (Relationship to Patient if Signed by Guardian)
A photocopy of this authorization may be treated in the same manner as an original.
Combined Insurance Company of America
Claim Department • PO Box 6700 • Scranton, PA 18505-0700 Telephone 1-800-225-4500 Fax 312-351-6930
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Form 104280-C09 CICA combinedinsurance.com

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Completed 4 December 2019

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