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First choice claim form

First choice claim form 2026

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The document is a claim submission form for First Choice Health Administrators (FCHA), detailing the necessary information required from members or patients to process health insurance claims. It includes sections for member and patient details, other insurance coverage, patient condition, and certification of information accuracy. The form also addresses potential injuries and related legal actions.

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Click ‘Get Form’ to open the first choice claim form in the editor.
Begin by filling out the MEMBER/PATIENT section. Enter the member's name, address, and indicate if this is a new address. Provide the patient's name, member number, group number, birth date, and relationship to the member.
If applicable, complete the OTHER INSURANCE section. Fill in the policyholder’s details and insurance carrier information. Indicate the type of coverage and whether the patient has Medicare benefits.
In the PATIENT CONDITION section, describe services provided along with diagnosis codes. If related to an injury, answer questions regarding claims against other parties and attorney representation.
Finally, review all entered information for accuracy. Sign and date at the bottom of the form to certify correctness before submission.

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