Allstate benefits outpatient claim form 2025

1. Click ‘Get Form’ to open the Allstate Benefits Outpatient Claim Form in the editor.
2. Begin by filling out the Policyholder/Certificateholder Information section. Enter your policy number(s), first name, middle initial, last name, social security number, date of birth, mailing address, and phone number.
3. Next, provide the Patient’s Information. Include the patient's first name, middle initial, last name, social security number, date of birth, relation to insured (self, spouse, child), and gender.
4. In the Outpatient Physician’s Treatment Benefit section, specify the provider's name and address. Include the dates of service and attach any required documentation such as bills or treatment records.
5. If applicable, complete the Assignment of Benefits section by providing details for where benefits should be sent. Ensure you include the provider's tax identification number.
6. Finally, read and sign the Certification section to confirm that all information is accurate. Make sure to date your signature before submitting.

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