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Web we would like to show you a description here but the site won’t allow us. Download a claim form for medical services, pharmacy services or overseas care. Web services received outside the united states, puerto rico, jamaica and the u.s. On the next screen, choose claims forms. Send completed form and documentation to: Check page 2 for instructions about submitting your. Please see the instructions on the reverse side of this form before completing. Click the link to download the “international claim form”. For filing instructions for other claim types (e.g., dental, prescription drugs, etc.).
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Web services received outside the united states, puerto rico, jamaica and the u.s. Check page 2 for instructions about submitting your. Download a claim form for medical services, pharmacy services or overseas care. On the next screen, choose claims forms.
Click The Link To Download The “International Claim Form”.
Web we would like to show you a description here but the site won’t allow us. Send completed form and documentation to: Please see the instructions on the reverse side of this form before completing.