STATEMENT OF CLAIM FOR SHORT TERM RECOVERY - EBView 2026

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The document provides detailed instructions for submitting a claim form for short-term recovery benefits. It outlines the necessary information to be filled out, required documentation such as hospital bills and treatment plans, and the mailing address for claims submission. Additionally, it includes legal disclaimers regarding fraudulent claims and an authorization section for obtaining medical information.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the 'Insured Member' section completely, including your Certificate Number, Name, Birth Date, and Contact Information.
In the 'Insured's Statement' section, provide details about the claim, including the nature of injury or sickness and dates of treatment. Ensure you answer all questions accurately.
Attach any required documentation such as hospital bills or Medicare EOBs. This is crucial for processing your claim efficiently.
Review all entries for accuracy before signing and dating pages 2, 3, and 4. Your signature confirms the information provided is correct.
Finally, submit your completed form along with all necessary documents to the address provided in the instructions.

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