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Instructions for Claim Submission Please be sure to

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For Claims Customer Service: Phone: 877-201-9373 x45704
For Claims Submission: Fax: (508) 471-3208 Email: RiderClaims@Trustmarkins.com
Mail: PO Box 60676, Worcester, MA 01606
V11.16
Wellness /Health Screening Claim
Instructions for Claim Submission
Please be sure to attach copies of Outpatient Bills / Invoices or
Explanation of Benefits to support the testing/services you had
completed.
Please complete a SEPARATE form for each individual and/or
calendar year that you are claiming benefits.
• Section A, B & C - Complete these sections in full and return for review of
benefits. Incomplete or illegible answers may result in delay of benefits.
Please keep a copy of all parts of this form and any attachments for your
records.
• Section D – Complete only if services/testing provided through an employer
sponsored wellness clinic for which you have no other documentation.
• Electronic Communication and State Required Fraud Language: Attached for
your information.
• Insured Statement of Claim Communication: Please complete the Third Party
Authorization if you would like to authorize Trustmark to release information on
your claim(s) to a third party such as a spouse, friend or agent.
For Claims Customer Service: Phone: 877-201-9373 x45704
For Claims Submission: Fax: (508) 471-3208 Email: RiderClaims@Trustmarkins.com
Mail: PO Box 60676, Worcester, MA 01606
V11.16
Wellness /Health Screening Claim
Section A – Policyholder Information (To Be completed by the Policy Owner) Policy #: _____________________
SSN#______/____/______
Name: ______________________________________ DOB: ____/____/____ Phone #__________________Home Cell Work
Address: _____________________________________________________________________________________________
Street City State Zip Code
Section B – Patient Information (To Be completed by the Policy Owner)
Please complete below and attach itemized copies of any related bill supporting the testing you or the patient had completed.
If MA issued policy mammogram and pap smear documentation must include actual cost.
Name of patient: ____________________________________ DOB: _____/____/____ SSN: ______-______-________
Relationship to Insured: ______________________________________(e.g. spouse, son, daughter)
This is not a guarantee of payment. Benefits will be determined based on your policy and rider provisions. Please note which
test/service you had completed by providing the date it was completed below.
TEST OR SERVICE
Date Completed
TEST OR SERVICE
Date Completed
Low Dose Mammography
/ /
Stress test on a bicycle or treadmill
/ /
Breast ultrasound
/ /
Hemoccult Stool Specimen
/ /
Pap Smear for women over age 18
/ /
Flexible Sigmoidoscopy
/ /
Colonoscopy
/ /
CA 15-3 (blood test for breast cancer)
/ /
Fasting blood glucose test
/ /
CA125 (blood test for ovarian cancer)
/ /
Serum cholesterol test to determine
levels of HDL and LDL
/ /
CEA (blood test for colon cancer)
/ /
Blood test for triglycerides
/ /
Serum Protein Electrophoresis (blood
test for myeloma)
/ /
Prostate Specific Antigen
/ /
Thermography
/ /
Chest X-ray
/ /
Bone marrow testing
/ /
Some select accident policies include a Wellness Rider that provides coverage for two additional services. If you have an accident
policy that includes the Wellness Rider please complete below if you are claiming either of the following services.
WELLNESS TEST OR SERVICE
Date Completed
WELLNESS TEST OR SERVICE
Date Completed
Immunization
(Please indicate for what):
/ / Routine Physicals / /
Section C: Please sign, print your name and date below to certify to the accuracy of information provided.
_________________________________ ______/_____/______
Policy Owner Signature Print Name Date
Section D: Complete only if the claimed testing was completed as part of a Wellness Clinic through your employer and you do not
have documentation of the date and type of testing completed. To be completed by Medical Professional who provided the testing.
____________________________ ____/_____/_____
Medical Professional Signature Print Name Date
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For Claims Customer Service: Phone: 877-201-9373 x45704
For Claims Submission: Fax: (508) 471-3208 Email: RiderClaims@Trustmarkins.com
Mail: PO Box 60676, Worcester, MA 01606
V11.16
Wellness /Health Screening Claim
Electronic Communication: If you choose to communicate with us electronically, you should be aware that electronic
communication is not secure unless it is encrypted. We strongly encourage you to use encrypted communication when sending
sensitive and/or confidential information. By sending sensitive or confidential electronic messages that are not encrypted, you
accept the risks of such lack of security and possible lack of confidentiality. If you elect to communicate from your workplace
computer, you should also be aware that your employer and its agents have access to email communication between you and us.
State Required Fraud Warnings
Fraud Statement for Alaska and New Hampshire Residents: 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.
Fraud Statement for AZ Residents: 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.
Fraud Statement for CA Residents: For your protection, California law requires the following to appear: 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.
Fraud Statement for CO Residents: 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.
Fraud Statement for FL Residents: 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.
Fraud Statement for Kansas, and Oregon Residents: Any person who knowingly, and with the intent to injure, defraud, or deceive an insurance
company, files a statement of claim containing any false, incomplete, or misleading information may be guilty of insurance fraud, which may be a crime.
Fraud Statement for KY Residents: A 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.
Fraud Statement for Arkansas, Louisiana, New Mexico, Texas, and West Virginia Residents: 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.
Fraud Statement for Maryland Residents: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit
or knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in
prison.
Fraud Statement for MN Residents: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
FRAUD STATEMENT FOR PENNSYLVANIA RESIDENTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE
COMPANY OR OTHER PERSON FILES ANY 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.
Fraud Statement for New Jersey: ANY PERSON WHO KNOWINGLY FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR MISLEADING
INFORMATION IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
Fraud Statement for Ohio Residents: 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.
FRAUD STATEMENT FOR DISTRICT OF COLUMBIA, MAINE, TENNESSEE, VIRGINIA AND WASHINGTON RESIDENTS: 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.
Fraud Warning for Delaware, Idaho, Indiana, and Oklahoma, As Well as for the Residents of All States Not
Specifically Listed WARNING: Any person who knowingly, and with the intent to injure, defraud, or deceive an insurance
company, files a statement of claim containing any false, incomplete, or misleading information may be guilty of insurance
fraud, which is a felony.
For Claims Customer Service: Phone: 877-201-9373 x45704
For Claims Submission: Fax: (508) 471-3208 Email: RiderClaims@Trustmarkins.com
Mail: PO Box 60676, Worcester, MA 01606
V11.16
Wellness /Health Screening Claim
Insured Statement of Claim – Communication
Third Party Communication Authorization
Please complete this authorization if you would like us to discuss, to release, or to provide information to a family
member, friend, or other third party such as your agent or employer.
My Spouse or Partner: (Name)_______________________________________________________________________
☐ All Information (All policy and claim information)
☐ All Information except Medical Information (diagnosis, medical condition, reason for claim, treatment, physicians)
My Family Member: (Name and Relationship)_____________________________________________________________
☐ All Information (All policy and claim information)
☐ All Information except Medical Information (diagnosis, medical condition, reason for claim, treatment, physicians)
Other Third Party: My Agent: Yes ☐ My Employer: Yes ☐
Or Name a Specific Third Party (Name and Relationship) ___________________________________________________
☐ All Information (All policy and claim information)
☐ All Information except Medical Information (diagnosis, medical condition, reason for claim, treatment, physicians)
I agree that if I authorize release of all claim information this may include health information which may be related to
disorders of the immune system including but not limited to HIV and AIDS, use of alcohol or drugs, mental and physical
condition, history, or treatment.
I understand that any information shared may be subject to re-disclosure and might not be protected by certain federal
regulations governing the privacy of health information relative to my condition.
Authorization
I may revoke or update this authorization in writing at any time or by email to
Riderclaims@trustmarkins.com.
Trustmark Insurance may rely on the information I provide for the adjudication of my claim as a result of this
authorization until receipt of my revocation notice. This authorization is valid for two (2) years. I may request a copy of
this authorization and a copy is as valid as the original.
Policy Owner (Or Policy Owner’s Personal Representative’s Signature Date
- -
Printed Name Social Security Number
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Completed 11 March 2021

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