MP+ Claim Form
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Please follow these instructions prior to filing a claim and when completing the claim form. Assistance is also available from the International
Medical Group® (IMG®) Customer Service Department at the telephone numbers listed above.
Our goal at IMG is to process your claim quickly, accurately and efficiently. In order to achieve this, the Claim Form must be fully and accurately
completed. Failure to do this will result in processing delays.
MP+ International Claim Form
& Authorization Filing Instructions
Precertification (notification of illness or accident):
You must call IMG to precertify any of the following conditions: any treatment requiring hospitalization; outpatient surgery, CAT scans, within 48
hours after an emergency admission to the hospital; care in an extended care facility; home nursing care; durable medical equipment including
artificial limbs; or transplants. Precertification may be done by you, a relative, or a hospital representative.
Independent Preferred Provider Organization (PPO): Your plan may recommend you receive treatment from a provider within the US PPO. You
may access a listing of physicians or facilities by:
Using the IMG website, This provides a complete listing of providers by specialty and geographic location.
Contact the IMG Customer Service Department at the telephone number or mailing address listed below for a list of providers in your area.
Please note, due to the size of the PPO network we can only send directories for your immediate area.
When receiving treatment from a PPO provider, please follow these instructions:
Present your IMG medical identification card to the provider.
Request that the provider send the bill directly to IMG. Please note, if you pay directly to the provider for an eligible expense this will likely
affect your reimbursement from IMG. The negotiated fee for services will be the maximum reimbursement, whether paid to the provider
or to you.
Complete the Claim Form and submit it with all bills or invoices. If the provider has filed the claims on your behalf, simply forward the
completed Claim Form to IMG.
When receiving treatment from a PPO provider for eligible expenses, the submitted bills must be re-priced through the PPO to the
negotiated rate. This procedure may extend the normal processing time of your claim.
If this is a new claim, complete ALL PARTS of the Claim Form. If treatment was received in the United States you do not need to complete
If this is a continuing claim, complete PARTS A AND D. If treatment was received outside of the United States, you should also complete
Attach all itemized bills, statements and invoices for services and supplies.
Please make certain that all documents indicate claimant’s name, date of service, diagnosis and the itemized charges.
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
MP+ Claim Form
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DIRECTIONS FOR SUBMITTING A CLAIM: There are four parts to this form—A, B, C, & D. Please carefully review the instructions below.
If this a new claim, complete ALL PARTS of this form. If treatment was received in the United States you do not need to complete PART C.
If this is a continuing claim, complete PARTS A & D. If treatment was received outside of the United States, you should also complete PART C.
Attach all itemized bills, statements, and invoices for services and supplies.
Please make certain that all documents indicate claimant’s name, date of service, diagnosis, and the itemized charges.
Notice: Any false statement, concealment or fraud shall render this insurance null and void and all claims hereunder shall be forfeited.
PART A. To be completed by the claimant for all claims
Claimant/Patient Name:
(As it appears on ID card)
Passport/Visa Number:
Male Female
Date of Birth:
___/___/___ (MM/ DD/YYYY)
Claimant’s Relationship to Primary Insured: Self Spouse Child Other
Name of Primary Insured:
(As it appears on ID card)
Insured ID #:
Male Female
Date of Birth:
___/___/___ (MM/ DD/YYYY)
Home Country Address:
Current Address: City:
State: Postal Code: Home Phone: Work Phone:
Communications should be sent via email to:
Are you a full-time student?
Yes No
If yes, please provide name of school, address and phone number:
How many months of the year are you residing in the U.S.?
Street Address: Phone:
City: State: Postal Code: Country:
If claimant is or may be covered by other coverage, complete items below
Name of Primary Insured:
(As it appears on ID card)
Date of Birth: ___/___/___ (MM/ DD/YYYY)
Group # of other plan: ID # for other coverage:
Insured mailing address: City: State: Postal Code:
Name of other carrier: Carrier Phone number:
Carrier address: City: State: Postal Code:
Name of employer: Employer Phone number:
Employer address: City: State: Postal Code:
MP+ Claim Form
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PART B. To be completed by the claimant for each new condition, injury, or illness (if you need additional space, please attach a separate sheet)
1. When did the first symptom of this condition begin? State the exact date if possible: ___/___/___ (MM/ DD/YYYY)
2. How did the condition begin? State fully all symptoms and describe the condition in detail after it began. For accidents, include pertinent
details such as how, when, and where the accident occurred.
3. Have you ever had or been treated for this type of condition before? Yes No
4. List all the names and addresses of the providers you have seen for this condition.
5. What sicknesses, diseases, illnesses, injuries, or other physical, medical, mental or nervous disorder, conditions, or ailments have you experienced
during the last five years? Please provide the name and/or description of each condition, dates of treatment, and name and address of the
facility and/or attending physician(s).
6. Is this condition the result of an accident, injury, or illness:
a. Related to employment? Yes No
If yes, are you applying for Worker’s Compensation benefits?
Yes No
b. Involving a motor vehicle or another persons actions? Yes No
If yes, list the names of parties involved, insurance carriers and policy numbers.
c. Was a report filed with any governmental or investigating entities? Yes No
If yes, please identify the department and the address where it was filed.
d. Was this accident related to an organized or sanctioned athletic activity, Yes No
involving regular or scheduled games and/or practice? If so, was an accident report filed with the sports coordinator? Please provide a copy
of any related accident reports.
e. In the event you have hired legal counsel, please provide IMG with the complete name, address and telephone number of the attorney.
MP+ Claim Form
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PART C. Complete for all treatment received outside of the United States.
Date of service
What type of
service and/or
name of drug
What was the
Type of
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
MP+ Claim Form
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If this form is signed by someone other than the patient or parent, such as a personal representative, legal representative, or guardian on behalf of the patient, submit the following: a copy of
a health care representative form, power of attorney, a court order or other documentation showing custody, or other legal documentation showing the authority of the legal representative
to act on the patient’s behalf.
Version 0719IN01200803A190731
PART E. Privacy and Confidentiality Release Form
By completing this form, you are providing your consent for IMG to discuss information regarding your claim with the person(s) listed below. Without this written
authorization, applicable laws do not permit IMG to discuss information protected under confidentiality and privacy laws with anyone other than your physician(s)
or provider(s) of service.
I authorize IMG to discuss my claim with ____________________________________ who is ______________________________________________
This authorization is valid for __________ months from the date signed (maximum of 12 months).
I give IMG permission to release
the following information:
(Please select and initial)
________________ Financial and claim information related to medical bills or claim form.
________________ Provider name, date of service, total charge, total amount paid, and date of payment.
________________ Insurance ID number and/or patient account number
Privacy and confidentiality laws do not permit the release or re-disclosure of medical records obtained from a medical provider. Your medical information
and records can be obtained directly from your medical provider.
I have read the contents of this form. I understand, agree, and allow IMG to use and release of my information as I have stated above. I also understand that
signing this form is of my own free will. I understand IMG does not require that I sign this form in order for me to receive treatment, payment, or for enrollment
or being eligible for benefits. I have the right to withdraw this approval at any time by giving written notice of my withdrawal to IMG. I understand that my
withdrawing this approval will not affect any action taken before I do so. I also understand that information thats released may be given out by the person
or group who receives it. If this happens, it may no longer be protected under the HIPAA Privacy Rule. I am entitled to a copy of this form.
Print Patient Name: _________________________________________________________
Insurance ID Number:
Signature of the Patient or parent if the patient is a minor child: X _______________________________________
Date: ___/___/___ (MM/ DD/YYYY)
PART D. AUTHORIZATIONto 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 health plan, health care provider,
health care professional, MIB, federal, state or local government agency, insurance or reinsuring company, consumer reporting agency, employer, benefit plan,
or any other organization or person that has any records or knowledge of my health, has any information available as to diagnosis, treatment and prognosis
with respect to any physical or mental condition and/or treatment of me, and any non-medical information about me, to disclose my entire medical record, file,
history, medications, and any other information concerning me and to give any and all such information to my agent of record and authorized representatives of
Company, IMG, and their affiliates, and subsidiaries. Individuals have the right to refuse to sign the authorization without negative consequences to treatment or
plan enrollment, except IMG will not be able to administer claims, determine benefit eligibility, or issue payments. The authorization is valid for the term of the
insurance contract or plan under which a claim has been submitted.
I understand that I have the right to receive a copy of this authorization upon request and revoke the authorization at any time in a written communication to
IMG. A copy of this shall be as valid as the original. I acknowledge and understand there is the potential for the information to be subject to re-disclosure by the
recipient and to no longer be protected by applicable privacy and confidentiality laws.
Any person who knowingly presents a false or fraudulent claim for payment of a loss of 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.
Print Name of Insured: __________________________________________________________________________________________________________
Signature of Insured/Legal Representative: X _______________________________________________________
Date: ___/___/___ (MM/ DD/YYYY)
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 the Insured/Legal Representative: X ___________________________________________________
Date: ___/___/___ (MM/ DD/YYYY)
If needed you can overnight packages to following address:
2960 North Meridian Street, Indianapolis, IN 46208