Doctors claim form: Fill out & sign online

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01. Edit your form online

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Click ‘Get Form’ to open the Doctor's Office Visit Claim in the editor.
Begin by filling out the Claimant Statement section. Enter the claimant's name, date of birth, and Social Security Number (SSN). Indicate the relationship to the policy owner.
In the Policy Owner Information section, provide details such as name, address, email, and SSN if different from the claimant.
Specify the type of claims you are filing by checking the appropriate boxes for Doctor Office Visit, Telemedicine, or Prescription Drugs.
Complete the visit details for each physician or facility visited. Include dates of visits and check whether they were in-office or telemedicine appointments.
If applicable, fill out the prescriptions section by providing pharmacy names, prescription numbers, and dates filled. Attach copies of receipts.
Review all entries for accuracy. Sign and date where indicated to certify that all information is correct before submitting your claim.

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