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Click ‘Get Form’ to open the form pipe trades in the editor.
Begin with Part I: Participant & Spouse Information. Fill in the required fields for both the participant and spouse, including names, Social Security Number (last four digits), date of birth, and address.
Proceed to Part II: Patient Information. Enter the patient's name, address (if different), marital status, relationship to the participant, and gender.
In Part III: Other Coverage or Benefits, indicate if the patient has other coverage. If yes, provide details about the policy holder and insurance information.
Move to Part IV: Claim Information. Specify whether this claim is for a new injury or illness and provide a detailed description of how it occurred, including location and time.
Finally, complete Part V: Authorization by signing and dating where indicated. Ensure all sections are filled out accurately to avoid delays.

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