LC 7363 0 TRICARE Statement of Claim & Auth to Release EBView Form

LC-7564-4 ROA Page 1 of 2 07/2013 Important - Please read the statement that applies to your state of residence. Reserve Officers Association Health Insurance Claim Form Before completing please read all instructions carefully to insure fast accurate processing* INSTRUCTIONS ON HOW TO SUBMIT A CLAIM FORM 1. The form must be completed with all requested information* Sign and date the reverse side of form* 2. Complete Section 2 only if you want us to pay your insurance benefits to the provider for example doctor clinic hospital etc* 3. Enclose a copy of your TRICARE Explanation of Benefits form* Put your certificate number on the copy. 4. For TRICARE Supplements if services were provided in a Civilian Hospital please attach a copy of the TRICARE Explanation of Benefits Form if services were provided in a Government Hospital a copy of your Subsistence Receipt is needed If you have TRICARE Prime Coverage please submit a copy of your bill showing amount of charges and also the copayment amount. 5. If your claim for benefits is under the Hospital Income Plan send a copy of the hospital bill showing admission and discharge dates. 6. Mail Claims to Reserve Officers Association P. O. Box 10403 DesMoines IA 50306-0403 Section 1 - Claimant s Statement Please only one patient per form Insurance number as shown on your ID card and schedule of benefits billing notice 020Name of Member Last First Middle Initial Date of Birth Telephone Number Address Street City State Zip Code Name of Patient Gender Male Address of Patient Street City State Zip Code Relationship to Member Spouse Daughter Son Other Female Have you claimed benefits for this condition previously Yes No If yes when Diagnosis or Description of Condition Section 2 - Assignment of Benefits Complete this section only when you wish payment to be made directly to the provider s of service. If more than one provider list each one on a separate piece of paper. Provider s Name Hospital Doctor etc* Provider s Telephone Number Provider s Address Section 3 - Need Help Have Questions Call 1-800-247-7988 Any 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. In the majority of cases the information contained on this form is all that is required to process a claim* In some cases additional information is needed requiring the claimant to complete and submit a more detailed form* The Hartford is The Hartford Financial Services Group Inc* and its subsidiaries including issuing company Hartford Life and Accident Insurance Company Hartford Life Insurance Company Simsbury CT 06089. Complete the information on the bottom of the page. For residents of all states EXCEPT California Colorado Florida Kentucky Maine Maryland New Jersey New York Oregon Pennsylvania Puerto Rico Tennessee Virginia and Washington 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* who knowingly presents 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* insurance company for the purpose of defrauding or attempting to defraud the company.