Great west life forms healthcare expenses statement 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Part 1: Employee Information. Fill in your Plan Number, Division Number, and Employee Identification Number. Ensure your name, address, date of birth, and contact numbers are accurate.
3. Move to Part 2: Coordination of Benefits. Answer whether you or any family member has benefits under another plan. If yes, provide the necessary details including the other insurance company’s name and policy number.
4. In Part 3: Dependent Information, list dependents and their relationship to you. Indicate if they reside with you and their employment status.
5. Proceed to Part 4: Claim Details. Itemize each expense by entering the patient’s name, date of birth, type of expense, and total charge for each receipt.
6. Finally, review all sections for completeness before signing at the bottom of the form. Ensure all information is true and correct.

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