Fillable International Educators Claim Form (International Medical Group)

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International Educators Claim Form (International Medical Group)

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The International Educators Claim Form (International Medical Group) form is 3 pages long and contains:

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  • 3 check-boxes
  • 158 other fields

Country of origin: US
File type: PDF

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International Educators Claim Form
Page 1 of 3
WWW.IMGLOBAL.COM
PART A.
Who is this Claimant? Primary Insured Dependent
PRIMARY INSURED INFORMATION DEPENDENT INFORMATION
Name:
Male Female Spouse Child
Male Female Married Single
Date of Birth:
___/___/___ (MM/ DD/YYYY)
Date of Birth: ___/___/___ (MM/ DD/YYYY)
Address:
Address:
Phone:
Phone: Email:
Email: Fax:
Fax: Relationship to insured:
Policy#:
Date dependent insurance began: ___/___/___ (MM/ DD/YYYY)
Name of Employer:
PART B. Describe Injury or Illness
Where injury / illness occurred:
Date occurred:
___/___/___ (MM/ DD/YYYY)
If injury, how it occurred:
Did injury occur while working?
Yes No
Is injury due to an auto accident?
Yes No
Are you covered by other insurance?
Yes No
Policy #:
Name of other insurance company:
PART C. PAYMENT INFORMATION Please furnish an address for an Explanation of Benefits (EOB) and/or a reimbursement.
Address to send funds/EOB:
Electronic Transfer Information:
Name of Bank:
Name of Bank account holder:
Bank location/ address:
Bank account number:
Bank ID# or ABA/ Swift number:
International Educators
Claim Form
ALTERNATE PAYEE INFORMATION
Name:
Street Address: Phone:
City: State: Postal Code: Country:
Email:
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
International Educators Claim Form
Page 2 of 3
WWW.IMGLOBAL.COM
PART E. Complete for all treatment received outside of the United States.
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
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:
PART D. 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
International Educators Claim Form
Page 3 of 3
WWW.IMGLOBAL.COM
PART F. AUTHORIZATION—to be completed by the claimant for all claims.
I verify that all information contained in this form is true, correct, and complete to the best of my knowledge.
I authorize any licensed doctor, practitioner of the healing arts, hospital, clinic, health related facility, pharmacy, government agency, insurance company,
group policyholder, employee or benefit plan administrator having information as to the care, advice, treatment, diagnosis or prognosis of any physical or
mental condition, or the financial or employment status of the insured named below, to provide this information to International Medical Group®, Inc. or any
agent or administrator acting on its behalf.
I understand that I have the right to receive a copy of this authorization upon request. A copy of this shall be as valid as the original. This authorization is
valid for twelve months from the date signed.
Print Name of Insured: ________________________________________________________________________
ID #:
Signature of Insured/Guardian: X _______________________________________________________________
Date: ___/___/___ (MM/ DD/YYYY)
AUTHORIZATION:
I authorize payment of any benefits for eligible medical expenses to the provider or other supplier of services which is entitled to payment of the attached bills.
Signature of Insured/Guardian: X
_______________________________________________________________
Date: ___/___/___ (MM/ DD/YYYY)
Version 0719IN01200801A190731
If needed you can overnight packages to following address:
2960 North Meridian Street, Indianapolis, IN 46208
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International Educators Claim Form (International Medical Group)

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Completed 14 June 2021

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