Transcription of SUBMIT YOUR WELLNESS BENEFIT REQUEST Complete all …
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SUBMIT YOUR WELLNESS BENEFIT REQUEST Complete all …
SECTION 1: POLICYHOLDER INFORMATIONP olicyholder Name (last, first, middle)Date of BirthSocial Security AddressAddress (street, city, state, and ZIP) Benefits will be sent to this NameGroup Policy 2: PATIENT INFORMATIONP atient Name (last, first, middle)Date of BirthSocial Security of Service/TestRelationship to Policyholder Self Spouse DependentService/Test Performed Routine Exam/Physical Hearing Exam Vision Exam Dental X-Ray Chest X-Ray Flexible Sigmoidoscopy Hemocult Stool Specimen Colonoscopy Ultrasound EKG Echocardiogram Fasting Blood Glucose Test Stress Test (bicycle or treadmill) Thermography Breast MRI Mammogram If PA resident, provide cost.
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 and subjects such person to criminal and civil penalties.
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