SAG-AFTRA HEALTH PLAN
3601 W. Olive Ave., Burbank, CA 91505 • Mailing Address: P.O. Box 7830, Burbank, CA 91510-7830
P (800) 777-4013 • F (818) 953-9880 • www.sagaftraplans.org/health
Any person who knowingly and with intent to injure, defraud, or deceive files a statement of claim containing any false, incomplete, or
misleading information may be guilty of a criminal act punishable under law. Please be advised that no rights under the Plan, including but not
limited to the right to receive any benefit or any right to pursue a Claim or cause of action, are assignable to another party. For more
information see the “Authorized Representatives” section on page 102 of the SPD.
Medical Claim Form
Instructions for filing a claim:
If you have other insurance as your primary coverage, submit your bills to your other health insurance carrier first. When
you receive its Explanation of Benefits (EOB), attach a copy of it — along with an itemized bill — to this claim form and
follow instructions 1 through 3 below for filing a claim with the SAG-AFTRA Health Plan (Plan).
1. Complete this form (required for each family member).
2. Sign and date the form. The participant must sign and date this form. In addition, the spouse’s signature is
required if the claim is for a spouse.
3. Mail the form to the mailing address indicated above.
Participant information
Name:
Participant health care ID (HCID):
Address:
City:
State:
Zip:
New address? Yes No
Home phone: ( ) -
Work phone ( ) -
Single Married Legally separated Divorced Widowed
Patient information
Name:
Birthdate: / /
Is patient covered by Medicare?
Yes No
Relationship to participant:
Self Spouse Child
Do you or other family members have medical health insurance other than the Plan? Yes No
Other health insurance coverage? Yes No If yes, complete below:
Name of insured:
Relationship:
Insurance ID #:
Name of other insurance:
Address:
City:
State:
Zip:
Phone: ( ) -
Is this claim due to an accident? Yes No If yes, complete below:
Location:
How did it occur?
Was illness or injury caused by the patient’s job? Yes No If yes, complete below:
Date of accident/injury: / /
Time:
Employer:
Have you/your dependent filed a claim for workers’ compensation benefits? Yes No
I/We jointly certify that the above information is true and correct. I/We hereby authorize all doctors, medical
practitioners, hospitals, pharmacies, or other institutions rendering care and treatment to furnish the SAG-AFTRA Health
Plan with full information regarding the care and treatment rendered (including copies of their records).
Participant signature Spouse signature (required if claim is for spouse) Date
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