Emergency Medical Claim Form

Claim for Emergency Medical Services

In order for your claim to be considered for payment: 1. This form must be completed in FULL 2. All itemized bill(s) and proof of payment(s) for this emergency must be attached 3. This form MUST be signed 4. In most cases, payment will be made to provider(s) unless proof of payment is furnished by the member or provider(s).

Patient Name(Required)

First Middle Last Suffix

Phone

Date of Birth

Sex

Patient Address

Street Address City State ZIP Code

Subscriber Name(Required)

First Middle Last Suffix

Relation to Patient

Phone

Subscriber Address

Street Address City State ZIP Code

Place of Illness/Injury

Incident Date

Time

Place of Emergency Care

Treatment Date

Time

Is the Patient covered by other medical insurance?

YES

If YES, Insurance Company name

Name of Policy Holder/Subscriber

Subscriber ID Number

Description(Required)

Member's description of how the emergency occurred:

Was an Ambulance used?

YES

Who called the Ambulance?

If hospitalized, name of hospital

Admit Date

Discharge Date

When did you notify CCHP?

With Whom did you speak?

Name of your CCHP Primary Care Physician

Was the injury or illness work-related?

YES

If yes, please attached an explanation of payment or denial from the workers' compensation carrier.

Max. file size: 20 MB.

Was the injury the result of a motor vehicle accident?

YES

If yes, please attach a copy of the auto policy face sheet for the vehicle in which the patient was riding.

Max. file size: 20 MB.

If you have retained an attorney, please give the attorney's contact information.

Attorney's Name

First Middle Last Suffix

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Phone

I authorize (Name of providers)

to release any and all information, including medical and/or hospital records pertaining to the health care services provided to me on/between the dates listed on this Claim for Emergency Medical Services. I understand that this information is necessary to allow CCHP to process my claims for payment of these services.

Provider 1

Provider 2

Provider 3

Authorizing Signature (Parent's signature, if the patient is a minor)(Required)

Date(Required)

Name

This field is for validation purposes and should be left unchanged.