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18006355597 2026
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- Click ‘Get Form’ to open the Health Screening Benefit Claim Form in the editor.
- 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.
- Indicate whether the patient is yourself or another individual by checking the appropriate box. Complete their details similarly as you did for yourself.
- 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.
- Review the Tax Considerations section and ensure you understand any potential tax implications related to your benefits.
- Sign and date the form in the Signature of Insured section, confirming that all information provided is true and complete.
- If applicable, complete the Optional Authorization to Disclose Information to Third Parties section before submitting your form.
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