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1. Click ‘Get Form’ to open the Health Screening Benefit Claim Form in the editor.
2. Begin by filling out the Insured/Patient Statement section. Provide your last name, first name, date of birth, and social security number. Ensure all information is accurate to avoid delays.
3. Indicate whether the patient is yourself or another individual by checking the appropriate box. Complete their details similarly as you did for yourself.
4. In the Health Screening/Wellness Benefit Claim section, check all tests performed and enter the corresponding dates. This section does not require proof of tests but must be filled accurately.
5. Review the Tax Considerations section and ensure you understand any potential tax implications related to your benefits.
6. Sign and date the form in the Signature of Insured section, confirming that all information provided is true and complete.
7. If applicable, complete the Optional Authorization to Disclose Information to Third Parties section before submitting your form.

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