Transcription of DISABILITY CLAIM FOR ACCIDENT & SICKNESS …
{{id}} {{{paragraph}}}
Example: quiz answers
DISABILITY CLAIM FOR ACCIDENT & SICKNESS …
Page 1 of 4A&S STD LTD UNI 5782 (07/05) eF DISABILITY CLAIM FOR ACCIDENT & SICKNESS (A&S)/ SHORT TERM DISABILITY (STD)/SALARY CONTINUANCEI nstructions for completing the CLAIM form:1. Complete all applicable areas of the CLAIM form. Please print Please sign a) bottom of this page and b) Fraud Faxing this CLAIM form will expedite receipt and eliminate your need to mail 1: To Be Completed by the EmployerName of Employer Group Report #Sub-Code # (Sub-Division) Sub-Point # (Branch)Address City State Zip CodeSubsidiary or Division NameContact Person s NamePhone # Contact Person s E-mail AddressFAX # Employee Name (First, MI, Last)Social Security ID #Date of HireJob TitleJob Class Sedentary Light Medium Heavy Very HeavyWork Location AddressWork Phone # Supervisor Name Supervisor s E-Mail AddressPhone # Is condition work related?
Page 3 of 4 A&S STD LTD UNI 5782 (07/05) eF Metropolitan Life Insurance Company P.O. Box 14590 Lexington, KY 40511-4590 Fax: 1-800-230-9531 HIPAA: This Authorization has been carefully and specifi cally drafted to permit disclosure of health …
Loading..
Tags:
Information
Domain:
Source:
Link to this page:
Please notify us if you found a problem with this document:
Related search queries
Summary of the HIPAA Privacy, HIPAA, HEALTH, Rules, INTERACTIVE HEALTH INFORMATION PRIVACY, Privacy, INTERACTIVE HEALTH INFORMATION PRIVACY STATEMENT, Texas Medicaid, TMHP, Texas Medicaid HIPAA, SOI Benefits Guidebook and Summary Plan, Employer, Plans, Your Exam Content Outline, Prometric, National Provider Identifier (NPI) Glossary of, Guideline for infection control in health