REIMBURSEMENT TRANSMITTAL CLAIM FORM 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Employee’s Name and Contract Number in the designated fields. Ensure accuracy as this information is crucial for processing your claim.
3. Next, fill in the Dependent’s Name and Employer’s Name. This helps identify who the claim is associated with.
4. Input the Policy Number, Diagnosis Code, and Procedure Code. These codes are essential for categorizing your claim correctly.
5. Describe the Service Rendered and provide details if services were rendered outside Puerto Rico, especially if your policy number starts with 3 or P.
6. Complete the Date of service and indicate if it was an accident. Provide additional details about how, when, and where it occurred.
7. Answer whether the claimant is insured with another health plan and provide termination dates if applicable.
8. Finally, sign the form as the Employee and ensure all required receipts are attached before submission.

Start using our platform today to streamline your claims process for free!