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How to use or fill out great west life forms healthcare expenses statement
- Click ‘Get Form’ to open it in the editor.
- 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.
- 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.
- In Part 3: Dependent Information, list dependents and their relationship to you. Indicate if they reside with you and their employment status.
- 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.
- 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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