Fillable INTERNATIONAL CLAIM FORM You may use the GEHA (GEHA)

Fill Online, Printable, Fillable, Blank INTERNATIONAL CLAIM FORM You may use the GEHA (GEHA) Form

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

INTERNATIONAL CLAIM FORM You may use the GEHA (GEHA)

On average this form takes 8 minutes to complete

The INTERNATIONAL CLAIM FORM You may use the GEHA (GEHA) form is 1 page long and contains:

  • 0 signatures
  • 0 check-boxes
  • 33 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your GEHA forms online.

BROWSE GEHA 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
 
INTERNATIONAL CLAIM FORM
You may use the GEHA International Claim Form to submit institutional and professional claims for benefits for services received outside the
United States. Please include the Provider’s itemized bill(s) with this form.
Name of Subscriber:
GEHA ID Number:
Name of Patient:
Patient’s date of birth:
Were these expenses the result of an accidental injury? Yes No
If “Yes,” please supply us with the following information: Accident date: ________________________ Time of accident: ____________________
Nature of accident: ___________________________________________________________________________________________________________
D
ate of
service
P
rovider name
and address
Type of
provider
(hosp., etc.)
D
escription
of service
R
ate of
exchange
Charge
Diagnosis
Authorization for assignment of benefits – Complete if you prefer that benefits be paid directly to the Provider of service.
I, the undersigned, authorize and request GEHA to make payment for benefits due herein to:
Name of Provider: __________________________________________________________________________________________________
Signature of Subscriber/Patient: ____________________________________________________ Date: ______________________________
Government Employees Health Association, Inc.
Foreign Claims Department
P.O. Box 21542 • Eagan, MN 55121 • Telephone: 800.821.6136 • Email: overseas@geha.com • Website: geha.com
20180816
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

INTERNATIONAL CLAIM FORM You may use the GEHA (GEHA)

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 21 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document