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Po box 7011 wyomissing pa 19610

Po box 7011 reading pa 19610-2026

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The document is a Statement of Claim for medical expenses that employees must complete to submit claims for covered medical services. It includes sections for employee and patient information, authorization to release medical information, and details about the claim such as the nature of the illness or accident. Employees are required to attach relevant bills and have their physician complete additional information on the form.

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Click ‘Get Form’ to open it in the editor.
Begin with PART A – Employee Information. Fill in your sex, name, birthdate, home address, member ID number, marital status, employer name, and group certificate number.
Proceed to PART B – Patient Information. Indicate if the claim is for yourself or a dependent. Complete the patient’s name, sex, and birthdate as required.
For claims related to accidents or illnesses, provide detailed information including dates and descriptions as prompted in questions 14 through 19.
Attach all relevant bills showing necessary details such as patient’s name and service type before submitting the form.

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loomis claims address

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