Medical Claim Form

For in-network services and most out-of-network services, the provider will file claims directly to The Employee Benefit Service Center. Most Plan Participants will not need a Medical Claim Form. It is helpful if a claim form is completed for each Plan Participant, to update or files on other coverage for the dependants, to update student status, and to obtain an updated legal release to allow us to research the medical neccessity of a claim.

This is a 2 part form, please both links to download the complete version of this form.

Click here  for Part 1 of the Printer Friendly version of this form which will open in it's own window.
Click here  for Part 2 of the Printer Friendly version of this form which will open in it's own window.

Print the form to your own printer. Note: You may need to adjust the size (percentage of enlargement/reduction) of the image, depending on your printer's configuration, to make the form fill the page properly.