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- Click ‘Get Form’ to open the pomco form in the editor.
- Begin by filling out the Patient Information Section. Enter the patient's name, relationship to the employee, and date of birth. Ensure all fields are completed accurately.
- Next, provide the employee's details including their name, social security number, and mailing address. This information is crucial for processing your claim.
- Indicate if the treatment is a result of an accident by selecting 'Yes' or 'No.' If applicable, provide additional details about the accident.
- Complete the Physician or Provider Information section by entering relevant details about your healthcare provider and any services rendered.
- Finally, review all entered information for accuracy before signing and submitting your form back to POMCO at the provided address.
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POMCO, indicating that services provided by LCGH on August 23, 2006, were not covered at all by POMCO. In a subsequent March 2007 statement of the case, the