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CLAIM FORM
GROUP POLICY
285630
FORWARD COMPLETED CLAIM FORM TO: FOREIGN SERVICE BENEFIT PLAN
1620 L STREET, NW, SUITE 800
WASHINGTON, DC 20036-5629Phone: (202) 833-4910
CHECK HERE
IF NEW
ADDRESS
SINCE LAST
SUBMISSION.
DATE
RELOCATED
PLEASE PRINT
TO BE COMPLETED BY INSURED MEMBER
All items must be answered in full before your claim can be processed.
PLEASE PRINT
Member’s full name Sex Date of Birth
Membe
r’s mailing address
(Number and Street) (City) (State) (Zip Code)
Member’s Subscriber ID Enrollment Code Self Only 401 Self Plus One 403 Self & Family 402
If claim is for a dependent, given name Relationship Date of Birth
Dependent’s marital status (check one) single married
Name of dependent’s employer
Describe Sickness/Accident Suffered
If Accident: (a) Date of accident
(Month) (Day) (Year) (Hour)
(b) How and where did accident occur?
Was accident or sickness work related? Yes No If “Yes” please contact your workers’ compensation office for guidance.
Physician’s Name Address
OTHER INSURANCE/MEDICARE COVERAGE INFORMATION
(See section on coordination of benefits in your Brochure)
IMPORTANT: This question must be answered and the form signed before claim can be processed.
(a)
Are you or any member of your family covered under any health plan other than
F
OREIGN
S
ERVICE
B
ENEFIT
P
LAN
? Yes No
(b) If answer is “Yes”, complete the following:
Person in whose name the other plan is issued
Name of all dependents covered under the other plan
Name of Insurance Company or Plan Effective Date
Address of Claims Office
Is this insurance through active employment? Employment Effective Date
Policy or Contract Number Is Plan Family or Self only coverage? (Check appropriate block)
(c) Is this other plan issued under a Group or Individual contract? (Check appropriate block)
IMPORTANT: Thi
s question must be
fully answered by persons age 65 or older and persons under age 65 receiving disability
benefits through Social Security.
Medicare coverage (see your official Brochure)
(a) Are you or any member of your family covered under Medicare? Yes No
(b) If “Yes”, indicate name of person and check the type of coverage.
SELF:
Hospital (Part A) Effective Date Medicare (Part B) Effective Date
SPOUSE: Hospital (Part A) Effective Date Medicare (Part B) Effective Date
DEPENDENT: Hospital (Part A) Effective Date Medicare (Part B) Effective Date
(c) If you or your spouse are 65 or over, indicate whether you are actively employed.
Self: Yes No Employer
Spouse: Yes No Employer
Authorization
for dire
ct
payment of
benefits.
I authorize payment directly to
(Print name of physician)
for the Medical and/or Surgical Benefits otherwise payable to me.
Date , 20 Signed
(Signature of member)
I certify the information on this form is complete and accurate.
Signature of patient or member Date
WARNING: Any intentional false statement in this application or willful misrepresentation relative thereto is a violation of the law punishable by
a fine of not more than $10,000, or imprisonment of not more than five years, or both. (18 U.S.C. 1001)
HAVE YOU ANSWERED EVERY QUESTION? HAVE YOU D
ATED AND SIGNED THIS FORM?
GC-16435 (12-17) A-POD1
click to sign
signature
click to edit
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