Fillable GlobeHopper Senior Claim Form Help Sheet (International Medical Group)

Fill Online, Printable, Fillable, Blank GlobeHopper Senior Claim Form Help Sheet (International Medical Group) Form

Use Fill to complete blank online INTERNATIONAL MEDICAL GROUP pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

GlobeHopper Senior Claim Form Help Sheet (International Medical Group)

On average this form takes 27 minutes to complete

The GlobeHopper Senior Claim Form Help Sheet (International Medical Group) form is 3 pages long and contains:

  • 0 signatures
  • 4 check-boxes
  • 107 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your International Medical Group forms online.

BROWSE INTERNATIONAL MEDICAL GROUP FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
GlobeHopper Senior Claim Form
Page 1 of 3
WWW.IMGLOBAL.COM
FIELD # FIELD NAME DESCRIPTION
1. Insured’s ID # Number found on front of IMG ID card
2. Insured’s Date of Birth/Gender Month (2 digits), Day (2 digits), Year (4 digits) M = Male, F = Female
3. Insured’s Name Surname, given name, and middle initial
4. Insured’s Address Address for claims information and Explanation of Benefits
5. Medicare ID# Number listed on Medicare card
6. Medicare Plan Type
Select Medicare Plan number(s) enrolled under
A – Hospital B – Medical C – Advantage D – Rx drugs
7. Medigap Plan
Select Medigap plan type (Should be on the front of the ID card)
A B C D F G K L M N
8.
Medicare Advantage or Medigap Policy
# and Insurance Information
Name of insurance carrier and contact information
9. Diagnosis Detailed description of illness or injury
10. Treatment Information
The date(s) the services were provided to the Insured and
the name and address of the provider. Detailed description of procedures, services, or supplies
provided, and currency and amount paid for services
11. Proof of Service(s) An itemized listing of services and payment from the practitioner or facility
12. Proof of Payment Documentation that validates and proves your payment
13. Signature of Insured Form must be signed by insured
International Medical Group®, Inc. (IMG®) reserves the right to request further information to support your claims.
GlobeHopper
SM
Senior
Claim Form Help Sheet
GlobeHopper Senior Claim Form
Page 2 of 3
WWW.IMGLOBAL.COM
Please print clearly, complete all sections, and sign. Retain a copy of all receipts and documents for your records.
1. Insured’s ID:
Gender:
Male Female
2. Date of Birth:
___/___/___ (MM/ DD/YYYY)
3. Insured’s Name: Last: First: Middle Initial:
4. Insured’s Address:
Street Address:
City: State/Province: Postal Code: Country:
Email Address:
5. Medicare ID Number: 8. Medicare Advantage or Medigap Policy:
6. Medicare Plan Type: Select Medicare Plan Type(s) Enrolled Under:
A. Hospital C. Medicare Advantage
B. Medical D. Rx Drugs
Policy Number:
Insurance Carrier:
7. Medigap
Plan: Select Medigap Plan Type:
A B C D F G K L M N
Address:
City/State/Postal Code:
GlobeHopper
SM
Senior
Claim Form
9. Diagnosis: What were you seen for? (e.g. flu, broken leg, cold, etc.)
Detailed Description of Illness or Injury:
10. Provide Proof of Services with the following:
Date of service
(MM/ DD/YYYY)
Provider
What type of
service and/or
name of drug
provided?
What was the
illness/injury?
City/
country
Type of
currency
paid or billed
Total charge
paid or billed
Converted to
U.S. funds
Office use only
11. Provide Proof of Services with the following:
An itemized bill from the provider of service, listing dates of service, services provided, and dollar amounts paid.
ALTERNATE PAYEE INFORMATION
Name:
Street Address: Phone:
City: State: Postal Code: Country:
Email:
International Medical Group®, Inc. (IMG®) reserves the right to request further information to support your claims.
Please print legibly and complete ALL SECTIONS of this form.
Mail, fax, or email completed form to:
Address: International Medical Group, Inc. Claims, P.O. Box 9162, Farmington Hills, MI 48333-9162 USA,
Call: +1.800.628.4664 or outside U.S. +1.317.655.4500; Fax: +1.317.655.4505
Email: customercare@imglobal.com
www.imglobal.com
GlobeHopper Senior Claim Form
Page 3 of 3
WWW.IMGLOBAL.COM
12. Proof of payment through one of the following (check which method applies):
Receipt of payment by provider for cash payments. Cash payments must also include proof for source of funds (e.g. Wire Transfer, Travelers Check, Check
Receipt, Credit Card Statement, Bank Statement)
Financial statement to include a copy of front and back of canceled check made out to the provider
Credit card statement including service receipt
PAYMENT DETAILS (Checks will only be issued to a United States address.)
Make payment to the provider
Make payment to primary insured
Reimbursement method
Bank ACH or wire transfer (complete below) Check
Make payment to alternate payee
Reimbursement method
Bank ACH or wire transfer (complete below) Check
Account Holder’s Name:
Bank Name:
Bank Address: City: Country:
Currency of reimbursement: Bank 9 digit ABA number—U.S. banks:
Bank 8 or 11 digit SWIFT code—non-U.S. banks: Sort code:
Bank account number: Bank IBAN:
Intermediary Bank Details (if applicable):
Name of intermediary bank:
Intermediary bank SWIFT code: Intermediary bank account number:
13. I hereby apply for benefits and certify that the above information is complete, true and correct. To all physicians and other medical professionals, hospitals,
and other medical care institutions, and insurers, medical or hospital service and prepaid health plans, employers and group policy holders, contract holders
or benefit plan administrators: You are authorized to provide the Plan and any benefit plan administrators from consumer reporting agencies, attorneys and
independent claim administrators acting on the Plan’s behalf, with information concerning medical care, advice, treatment or supplies provided to the Patient,
and any employment related information regarding the Patient. This information will be used for the purpose of evaluating and administering claims for benefits.
I understand that the duration of the authorization is for the term of coverage of the policy or contract under which a claim for health benefits has been submitted.
I understand that I have a right to receive a copy of this authorization upon request. I agree that a photographic copy of this authorization is as valid as the original.
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.
Form must be signed. Claim cannot be processed without member’s signature.
Signature of Insured: X___________________________________________________________________________
Date: ___/___/___ (MM/ DD/YYYY)
Signature of Subscriber, if insured is a minor: X_____________________________________________________
Date: ___/___/___ (MM/ DD/YYYY)
Version 0719IN01200798A190731
If needed you can overnight packages to following address:
2960 North Meridian Street, Indianapolis, IN 46208
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

GlobeHopper Senior Claim Form Help Sheet (International Medical Group)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 14 June 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document