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Colonial hospital confinement claim form

Hospital confinement claim form 2026

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The document is a Hospital Confinement Indemnity (GAP) Claim Form for Fidelity Security Life Insurance Company. It provides instructions for insured individuals to complete the form, including personal information, details about the patient and their condition, and necessary attachments like Explanation of Benefits (EOB). The form also includes an authorization for the release of health-related information and outlines fraud notices specific to various states.

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Click ‘Get Form’ to open the hospital confinement claim form in the editor.
Begin by filling out the 'Statement of Insured' section. Enter your name, date of birth, policy number, and social security number accurately.
Provide your address and contact information, ensuring all details are correct for effective communication.
Indicate the patient's relationship to you and fill in their details, including their date of birth.
Answer questions regarding Medicare coverage and other insurance plans. If applicable, provide details about any additional insurance coverage.
Describe the injury or sickness thoroughly, including dates of treatment and physician's information.
Review all entries for accuracy before signing the form at the bottom. Ensure you also complete the authorization section if required.

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Versions	Form popularity	Fillable & printable
2019	4.9 Satisfied (35 Votes)
2017	4.3 Satisfied (98 Votes)
2014	4.4 Satisfied (125 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Who fills out the UB-04 form?

The UB-04 uniform medical billing form is the standard claim form that institutional providers use, such as hospitals and community mental health care centers.

How to get a billing statement from a hospital?

Call the number for the hospitals billing department, typically located on the consolidated bill sent in the mail. Choose the relevant option to speak with a human about your bill. When a human picks up, ask: Id like an itemized statement. Could you post it to my online portal or mail me a copy directly?

Who fills out the hospital indemnity form?

Insured or Patient to complete section A and submit to Attending Physician for completion. Attending Physician to complete sections B and C. Attending Physician to submit the completed and signed Attending Physicians Statement and supporting documentation to the address or fax number listed above.

What claim form is used for inpatient hospital services?

The UB-04 claim form is used to submit claims for inpatient hospital accommodations (for example, medical/surgical intensive care, burn care and coronary care) and ancillary charges (for example, labor and delivery, anesthesiology and central services and supplies).

How do I print an UB-04 form?

Printing UB-04 Claims Select the UB-04 claims. Correct any errors in the UB-04 claims. Add additional information to the UB-04 forms. Right-click on an insurance claim or insurance carrier and select Print UB04 to print the UB-04 form and send it to your insurance carrier in the mail.

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How to get a UB-04 form from the hospital?

Your healthcare provider - You can request a sample UB-04 form from your healthcare provider. They may have a blank copy of the form that you can use as a reference. Commercial printing companies - Many companies specialize in printing medical forms, including the blank UB-04 form.

What is hospital confinement indemnity?

Depending on the plan, hospital indemnity insurance gives you cash payments to help you pay for the added expenses that may come while you recover. Typically plans pay based on the number of days of hospitalization.

Hospital confinement claim form 2026

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