First choice claim form 2025

1. Click ‘Get Form’ to open the first choice claim form in the editor.
2. Begin by filling out the MEMBER/PATIENT section. Enter the member's full name, address, and indicate if this is a new address. Provide the patient's name, member number, group number, city, state, birth date, zip code, and relationship to the member.
3. If applicable, complete the OTHER INSURANCE section. Fill in the policyholder’s details including their name and birth date. Include information about their insurance carrier and coverage types.
4. In the PATIENT CONDITION section, describe the services provided along with valid ICD diagnosis and CPT codes. If this claim is due to an injury, answer related questions regarding other claims or attorney representation.
5. Finally, review all entered information for accuracy. Sign and date at the bottom of the form to certify that all information is correct before submitting.

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