MEDICAL CLAIM FORM

Please fill in all information legibly and completely.

AUTHORIZATION TO RELEASE INFORMATION:

I hereby authorize any insurance company, prepayment organization, employer hospital, or physician

to release all information with respect to me or any of my dependents which may have a bearing on

the benefits payable under this or any other plan provider benefits or services. I hereby certify the

information provided is correct and to the best of my knowledge.

Signature of Patient or Parent (if patient is a minor) Date

PATIENT NAME

PATIENT’S BIRTHDATE

MEMBER NAME

PATIENT RELATIONSHIP TO MEMBER

MEMBER ID#

PHONE NUMBER

MEMBER HOME ADDRESS CITY STATE ZIP

DATE OF SERVICE IF INJURED, HOW AND WHERE DID THE ACCIDENT HAPPEN? WORK RELATED? YES____NO____

IS THE PATIENT COVERED UNDER ANY OTHER HEALTH INSURANCE PLAN? YES____NO____

POLICY NUMBER

NAME AND ADDRESS OF OTHER INSURANCE COMPANY

PROCEDURE FOR FILING A CLAIM

1. Please attach all medical bills relating to the claim(s). Missing or incomplete claim information could

delay processing and reimbursement.

a. Make sure the bills identify the patient.

b. All bills should show the date of treatment, description of service and amount of charges.

c. Procedure Codes and Diagnosis codes must be included or claim form will be returned.

d. Proof of payment or receipt must be attached or claim form will be returned.

e. All statements should have your identification number listed.

f. Mail to: University of Utah Health Plans

PO Box 45180

Salt Lake City, UT 84145-0180

g. Or fax to 801-281-6121 ATTN: Member Reimbursement

h. Or email to uuhp@hsc.utah.edu

Revised 01/20