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.
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
P
rovider name
Type of
provider
D
escription
R
ate of
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
