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How To File a Claim
You may download a USAble Life group health insurance division claim form in PDF (portable document format). This
file will allow you to print a copy for completing off-line.
Claim Form (19 KB PDF)
Once the form is completed, please sign and date it. Mail it to the following address:
USAble Life group health insurance division
P.O. Box 1151
Little Rock, AR 72203
A separate claim form must be submitted for each patient when sending bills to USAble
Life Group Health.
If you have a problem downloading the form, please e-mail
Customer Service.
The following is a breakdown of the claim form:
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1.
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Group Number and Name
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2.
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Employee's Social Security Number
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Sections 3-11 request information about the patient:
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3.
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Patient's Last Name, Complete First Name, Middle Initial
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4.
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Date of Birth (Month, Day, Year)
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5.
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Sex
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6.
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Patient's Relationship to Employee (Self, Spouse, Child, Other--specify)
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7.
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Diagnosis or Nature of Illness or Injury
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8.
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Was this an accident?
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9.
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If yes, date of accident
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10.
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Was this an automobile accident?
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11.
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Was the illness/accident related to employment?
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Sections 12 -14 request information about the employee (contract holder):
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12.
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Employee's Last Name, First Name, Middle Initial
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13.
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Assignment: Payment for this claim should be made to (Hospital, Doctor, Employee)
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14.
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Employee Address
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Sections 15-20 request other insurance information:
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15.
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Do you have other health insurance with a group or government program?
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16.
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Name of Insured
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17.
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Name and Address of Insured's Employer
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18.
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Name and Address of Other Insurance Company
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19.
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Policy Number (other company)
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20.
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Type of coverage (Single or Family); Has the other insurance company paid on this
claim? If yes, please submit a copy of their payment with these bills.
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