Medical Claim Forms – Member Portal

PROVIDER SUPPORT 1.855.275.1270, OPTION 4			MEDICAL CLAIM FORM Forward Form and Bills to: JIPA Network/Claims PO BOX 2788 Kennesaw, GA 30156-9114 USA fax: 1.770.810.3789 email: claims@jipanetwork.com
Group/Plan Name or Number:			Insured’s ID Number:
PART 1: MUST BE COMPLETED BY INSURER
Insured’s Last Name:	First:	Middle:	Patient’s Birth Date:	Patient’s ID Number:

Patient’s Last Name:	First:	Middle:	Patient’s Gender:	Patient’s Relationship to Insured:
			Female Male	Spouse Child Other
Street Address:			Home Phone #:	Cell Phone #:

City/Town:	Parish/State:	Zip/Postal Code:	Email:

Date the patient’s accident or sickness began:		Did accident happened at work?	Has claim been filed by workers?	Is the patient a full time student?
		Yes No	Yes No	Yes No
Name of School if enrolled:		Address of School if enrolled:

Is the insured or patient covered under any other plan?		If yes, provide Policy Number:	Last Name:	First Name:
Yes No
ASSIGNMENT OF BENEFITS
AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize any insurance company, prepayment organization, employer, hospital or physician to release all information with respect myself or any of my dependents which may have a bearing on the benefits payable under this or any other plan providing benefits. I certify the information provided is true and correct to the best of my knowledge.	AUTHORIZATION TO PAY BENEFITS TO PROVIDER(S): I hereby authorize payment of benefits directly to Providers submitting claims on my behalf. This payment shall not exceed my indebtedness to the Providers and I have agreed to pay, in a current manner, any charges determined to be not covered by the plan benefits.
PART 2: TO BE COMPLETED BY PROVIDER OF SERVICE
REPORT OF SERVICES (OR ATTACH AN ITEMIZED BILL)	Date patient first consulted yo for this condition: