r

,-'...........

__.,

....

Planned Employee Program

Administered

I Medical Claim
by
Iowa

3rr

PI_ mail complMecl fonn to: Principlll Mutual ute Inaurenc:e Campeny
Regional Claim Center One Lakeview Energy Center, Suite 840 3817 N.W. Expressway Oklahoma City, Oklahoma 73112 Telephone 1-4059495655 Toll free In Oklahoma 1-800-5226608 Outside Oklahoma 1-800-523-5665

Prlnclpel Mutual ute Inaurance Compeny

Des Moines,

Employe.

Directions

for Completing

Claim Form

1. For each new sickness or accident claim complete Parts A, B, and C below. 2. For continuing sickness or accident claims (where you previously have sent in a claim form for that sickness or accident) you need to complete only Parts A and C of this form. 3. Turn to reverse side of claim form and complete Patient's Name and sign Authorization To Pay if you wish benefits paid to Provider. 4. Have Patient's Physician or Supplier either complete their portion on the reverse side of claim form or attach an itemized bill that Includes diagnosis. 5. If the hospital requests verification of coverage, the hospital may call Principal Mutual Life Insurance Company toll free Nationwide 800-247-4695.

Part A
Employee's Name "bA-N I E.L S. S'v (..L-I II 1t,J Employee's Date of Birth ~_JJ:::.L~ ..l_ Employee's Employer J2.QJ4 5J1M..GS~.A.. >Mi STt,\",,-,U.. H Patient's Name(s) 'DAtJ1.l. ~. ~vJl:"4-,J Is Employee still working7 Yes EtNo 0 If "No" date last worked _ Spouse's Social Security No. --:::-:--:~__,..,.-Plan and 1.0. numbers (printed on Employ"'.

1.0. Card):

Plan

L S=io4~
0
Son

J.D.

444 -,).r
0

c.r4-1(1o

Part B
For whose expenses is claim being made? Patient's Date of Birth ~___j__
Self

Wife

Husband

Daughter

Step Child

Foster

Patient's Occupation

Child 0 _ _

Patient's illness or injury (if injury, describe accident including date and place) Date Patient's illness began Employee's employment Is spouse employed? Yes Did Patient's injury or illness result from employment?
__

___j___j

__

Yes

No
__

date

___j___j

Is Employee

Single

Married

Divorced

Widowed

0 0
_

If "Married", give spouse's name

Spouse's Date of Birth

___j___j

No

If "Yes" give name, address, and telephone no. of spouse's employer

Is patient covered by any other medical benefit plan, group policy, prepayment plan, Medicare or other Government plan? Yes 0 No 0 If "Yes" give name of Person carrying the other coverage _ Name of Group (employer, association, etc.) Name of Insurance Company or Plan Address of other Insurance Company's claim office These statements are true and complete to the best of my knowledge Policy or Plan No.
=-_--,,-::-....,-......,(Signature of Employee)

_ _ _
_

-:-=--:-

(Date)

Part C In order to process a claim for benefits, I authorize any physician, hospital or other medical provider to release to Principal Mutual Life Insurance Company of Des Moines, Iowa, or its representative, any information regarding my medical history, symptoms, treatment, examination results or diagnosis. A photocopy of this authorization shall be considered as effective and valid as the original. This authorization shall be considered valid for the duration of the claim, but not to exceed one year from the dat" signed. I"un~~nd I have the right to receive a copy of this authorization.
Date J

I(,/ff7

Signature of Employee Signature of Patient

/()~

Address of Employee

Street No.

&- //%;t.
I%l

S.,Xt(

!3 .

I
(Required only if patient is spouse)

(J~
City State

7~

Zip Code

Is this a new address? Yes

PE :J6S.2

No

Please Tum Over