Download healthy lifestyle/healthy screening/physician office visit claim form

 HEALTHY LIFESTYLE/HEALTHY SCREENING/PHYSICIAN OFFICE VISIT CLAIM FORM All eligible benefits will be paid directly to the Policyholder.
Policy Information
Policyholder Name: _________________________________ Policy Number(s): _________________________________ Claimant Name: __________________________________ Date of Birth: ______/______/__________ ☐Primary Insured ☐ Spouse ☐Dependent Claim Information
(Do Not Include Receipts, Statements, Itemized Bills, Or Other Claim Forms.) Healthy Lifestyle Benefit (Must be 18+) ☐Gym Membership ☐ Weight Loss Program ☐ Smoking Cessation Program ☐ Physical Examination Provider Name Provider Telephone Date of Service Healthy Screening and Diagnostic Test Benefit (Benefit not payable for testing done as the result of an injury.) Select type of screening or diagnostic test below:
□ A1C Diabetes Test □ Angiogram □ Biopsy □ Blood test for triglycerides □ Blood test to confirm elevated cardiac enzymes □ Bone Marrow testing □ Breast ultrasound □ Breast MRI □ CA 125 (blood test for ovarian cancer) □ CA 15‐3 (blood test for breast cancer) □ Cardiac C‐Reactive Protein □ CAT Scan □ CBC (Complete Blood Count) □ CEA (blood test for colon cancer) □ Chest X‐Ray □ Cholesterol □ Colonoscopy □ Complete Metabolic Panel □ Echocardiogram □ Electrocardiogram □ Estrogen Profile □ Fasting blood glucose test □ Flexible Sigmoidoscopy □ Glucose & A1C Diabetes Check □ Heart Catheterization □ Hemoccult stool analysis □ HIV Antibody □ Immunizations □ Liver Enzymes □ Mammography □ MRI (Magnetic Resonance Imaging) □ Neuroimaging Studies □ Pap Smear (Convention or Thin Prep) □ Physical Examinations □ Prothrombin Time (PT) & Partial Provider Name □ Thromboplastin Time (PTT) Activated □ PSA (blood test for prostate cancer) □ Rheumatoid Arthritis Factor □ Serum cholesterol test to determine HDL/LDL level □ Serum Protein Electrophoresis (blood test for myeloma) □ Sleep Studies □ Stress test on a bicycle or treadmill □ Testicular Ultrasound □ Testosterone Count □ Thallium Scan □ Thermography □ Thyroid Panel & Thyroid Stimulating Hormone (TSH) □ Virtual Colonoscopy □ Vitamin D 25‐Hydroxy Provider Telephone Date of Service
Physician Office Visit Indemnity Benefit ☐ Sickness ☐ Injury ☐Mental Health ☐Dental Provider Name Provider Telephone Date of Service Acknowledgment
All benefits of this Rider are per Covered Person and are subject to the terms, definitions, provisions, limitations and exclusions of the policy to which it is attached. Any Person who knowingly files a statement of claim containing false, incomplete or misleading information may be subject to civil and criminal penalties. The Provider listed above is authorized to validate the information I have provided. Primary Insured or Spouse Signature Date 137 Main St. Dubuque, IA 52001 / Toll Free: 877‐822‐0582 Claims: 866‐326‐4184 Fax: 563‐585‐5094 / Web: www.pltnm.com