Fillable WELLNESS BENEFIT Request Form Best phone number Email (Little Rock School District)

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WELLNESS BENEFIT Request Form Best phone number Email (Little Rock School District)

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WELLNESS BENEFIT
|
Request Form
Personal Information
List your personal information.
Insured’s name Social Security Number Birth date
..........................................................................................................................................................................................................................................................
Best phone number Email address
..........................................................................................................................................................................................................................................................
Home address
..........................................................................................................................................................................................................................................................
City State Zip
..........................................................................................................................................................................................................................................................
Employer Information
List your employer information.
Employer name Group policy number
..........................................................................................................................................................................................................................................................
Patient Information
List patient information.
Patient’s name Social Security Number Birth date
..........................................................................................................................................................................................................................................................
Relation to insured ❍ Self ❍ Spouse ❍ Dependent
..........................................................................................................................................................................................................................................................
Test/Service Performed
Select the test or treatment
you had done.
❍ Routine Exam/Physical ❍ Ultrasounds ❍ Biopsy
❍ Vision Exam
❍ EKG ❍ Cancer Prevention (Vaccine/Immunizations)
❍ Dental X-Ray
❍ Thermography ❍ CEA (blood test for colon cancer)
❍ Chest X-Ray
❍ Breast MRI ❍ PSA (blood test for prostate cancer)
❍ Flexible Sigmoidoscopy
❍ Mammogram* ❍ CA 15-3 (blood test for breast cancer)
❍ Hemocult Stool Specimen
❍ Pap Smear-ThinPrep* ❍ CA 125 (blood test for ovarian cancer)
❍ Colonoscopy
..........................................................................................................................................................................................................................................................
*For PA residents only, enter actual cost:
Mammogram cost:
................................................................
Pap Smear-ThinPrep cost:
............................................................................
Provider of Test/Service
Provide information on where
test/service was performed.
Name of medical facility
..........................................................................................................................................................................................................................................................
Performing physician’s name Date performed
..........................................................................................................................................................................................................................................................
Address
..........................................................................................................................................................................................................................................................
City State Zip Phone number
..........................................................................................................................................................................................................................................................
Signature
Sign and date this form.
I understand approved benefits will be sent to my home address listed above.
Insured’s signature Date
..........................................................................................................................................................................................................................................................
Best phone number
..........................................................................................................................................................................................................................................................
Send claim form to:
●
Attn: Claims Department
USAble Life
P.O. Box 1650
Little Rock, AR 72203-1650
●
Email: claims@usablelife.com
●
Fax: 501-235-8400
Thank you for selecting coverage from USAble Life.
●
Complete this form to request your calendar year Wellness Benefit (if applicable to your policy).
●
For clarity, the Insured is referred to as “you”, “your” and “patient” on this form.
You may reach us with any questions at 800-370-5856, Monday-Friday, 8:00 a.m. to 5:00 p.m. CT.
CL-WELLNESS (8-13)
Fraud Warning: Except as noted in the separate Fraud Notice, 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.
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WELLNESS BENEFIT Request Form Best phone number Email (Little Rock School District)

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Completed 28 December 2022

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