CLAIM FORM

BEFORE YOU FILL OUT THE CLAIM FORM, PLEASE REVIEW THESE GUIDELINES:

n Please make sure your provider completes section 7 (hospitals), section 8 (treating physician), and/or section 9 (other providers), including
complete name, address, and Tax ID number.

n Remember to sign the Claim Form.

n Complete all sections of the Claim Form in full using BLOCK CAPITALS.

n Have your health care provider sign and stamp the Claim Form.

n Complete a separate Claim Form for every patient and each incident.

n Include all original invoices with proof of payment.

n Make sure that we have a copy of the history of your present illness or condition.

n If you have another medical insurance policy, the claim must be processed first by the other insurer and then presented with an explanation of how it
was processed.

PLEASE TAKE INTO CONSIDERATION THE FOLLOWING INFORMATION RELATED TO SPECIFIC TYPES OF CLAIMS

n Laboratory costs must include a list of the tests performed.

n Pharmaceutical expenses must include a list of all the medications acquired and a copy of the prescription.

n For dependents between the ages of 19 and 24, submit a Certificate of Dependent Student and a written statement signed by the policyholder
attesting that the dependent’s marital status is single.

n In case of a surgical procedure or biopsy, a pathology report must be included.

n In case of nasal trauma, x-rays, radiology report, and emergency report must be included.

n When filing the first claim for a newborn child, a copy of the birth certificate must be included.

n In case of an automobile accident, the police report must be included. If a police report cannot be obtained, include a letter from the treating
physician with a full description of the accident. Also include an explanation of benefits from the auto insurance company. If the medical costs are not
covered under the auto insurance policy, include an explanation from the auto insurance company. If you do not have auto insurance, an explanatory
letter will be required.

FAILURE TO COMPLETE SECTIONS 7, 8 AND 9 MAY RESULT IN THE DENIAL OF CLAIM.

IF YOU FILL OUT THE CLAIM FORM CORRECTLY AND SEND US ALL THE NECESSARY SUPPORTING DOCUMENTS, THE TIME NEEDED TO
PROCESS YOUR CLAIM WILL BE GREATLY REDUCED.

IN CASE WE REQUEST ADDITIONAL INFORMATION TO ASSESS YOUR CLAIM, PLEASE REMEMBER THAT YOUR POLICY HAS A FILING
LIMIT OF 180 DAYS. TO AVOID DENIAL OF YOUR CLAIM, PLEASE SUBMIT THE REQUESTED INFORMATION WITHIN THE FILING LIMIT.

17901 Old Cutler Road, Suite 400 • Palmetto Bay, Florida 33157
Tel. +1 (868) 224 5748, +1 (305) 398 7400 • Fax +1 (305) 275 8484 • www.bupasalud.com • service@bupalatinamerica.com

USA Medical Services • 24 hour emergency

Tel. +1 (305) 275 1500 • Fax +1 (305) 275 1518 • Toll free +1 (800) 726 1203 • usamed@bupalatinamerica.com
1. POLICYHOLDER INFORMATION
Full name Policy number
Last name First name M.I.

DOB E-mail address

MM / DD / YY

Address

Home phone Work phone

Cell phone Fax

2. CLAIM AGAINST OTHER INSURANCE COMPANY

In connection with this diagnosis, illness, or accident, have you made a claim, or are you making a claim against any other insurance company or benefit
plan? n Yes n No
Name of company Policy number

3. PREFERRED METHOD OF REIMBURSEMENT (PLEASE √)

n Please send a check

n Please transfer the reimbursement to my bank account in the USA

n Please transfer the reimbursement to my bank account outside the USA

4. BANK ACCOUNT INFORMATION

Account holder

n Checking n Savings Account number

Name of beneficiary bank ABA number

(ACH transfers) For banks in the USA only

Branch number SWIFT code

For banks outside the USA

Address and additional

information

Final account (if any)

Name Account number

INTERMEDIARY BANK (PLEASE COMPLETE FOR TRANSFERS TO BENEFICIARY BANKS OUTSIDE THE USA)

Name of bank ABA / SWIFT /

Other

Address Account number

5. PATIENT INFORMATION

Full name DOB

Last name First name M.I. MM / DD / YY

Gender: Relation to policyholder:

n M n F n Self n Spouse n Child
6. DETAILS OF DIAGNOSIS, ILLNESS, OR ACCIDENT

Is this claim resulting from an accident? n Yes n No

If Yes, was the injury caused by the act or omission of a person other than then patient? n Yes n No

Place of accident n Auto n Home n Work n Other:

Diagnosis, nature of
illness, or type of accident

Date of first symptom Date of first consultation for this

or accident MM / DD / YY diagnosis, illness, or accident MM / DD / YY

Have similar symptoms occurred previously? n Yes n No When?

MM / DD / YY

7. IN CASE OF HOSPITALIZATION
Name of hospital
Tax ID number
Address

Period of hospitalization From To

MM / DD / YY MM / DD / YY MM / DD / YY

8. TO BE COMPLETED BY TREATING PHYSICIAN

I certify that the information provided in sections 6 and 7 is complete and correct to the best of my knowledge.

Name of treating physician

Tax ID number
Address

Signature and stamp Date MM / DD / YY

Registration/
license number
E-mail Telephone

9. OTHER PROVIDERS
Name of provider Tax ID number
Address

Telephone Date MM / DD / YY

10. DETAILS OF THE SERVICE PROVIDED

Date of service Service provider Description of service Currency Charges
MM / DD / YY

MM / DD / YY

MM / DD / YY

MM / DD / YY

MM / DD / YY

MM / DD / YY

MM / DD / YY

Total charges

Amount paid by the insured

Amount paid by other insurance

Balance due to provider

 ACKNOWLEDGEMENT
Any person who knowingly and with intent to defraud or deceive any insurance company by (1) filing an application for insurance or a claim containing
any materially false information or (2) concealing or misleading information concerning any material fact, commits a fraudulent insurance act that may be
considered a crime under applicable law.
The insurer, Bupa Worldwide Corporation, USA Medical Services, and/or any of their applicable related subsidiaries and affiliates will not engage in any
transactions with any parties or in any countries where otherwise prohibited by the laws in the United States of America. Please contact USA Medical
Services for more information about this restriction.
I certify that all of the information supplied in this Claim Form is complete, true and accurate.

AUTHORIZATION FOR PROVIDERS TO RELEASE HEALTH INFORMATION

USA Medical Services, Bupa Worldwide Corporation, and their affiliates (collectively “Bupa”) and the insurer may need to use my and/or my dependents'
protected health information including, without limitation, my and/or my dependents' medical records/history, prescription medication records, treatment
records and plans, or any other medical or pharmaceutical information which may be related to this claim. I hereby authorize any physician, hospital,
lab, pharmacy, or any other health care provider, health plan, employer/group policyholder or benefit plan administrator, the Medical Information Bureau
(MIB), or any other organization or person, including any member of my family having access to any medical records or knowledge of myself or my
health, to disclose such information to Bupa, its Business Associates, or its designated agents, and the insurer, to evaluate this claim for insurance benefits.
I understand that the proper adjudication of my claim is dependent upon my provision of all necessary health information. As such, my refusal to provide
this authorization may result in the denial of this claim.
I understand that:
• I am entitled to receive a copy of this authorization.
• A copy of this authorization shall be as valid as the original.
• The authorization shall be valid throughout the life-cycle of the claim, including adjudication, auditing, and quality control activities.
• I have the right to revoke this authorization by notifying Bupa in writing and subject to and in accordance with 45 C.F.R. §164.508. However, the
revocation will not be effective until Bupa receives and processes such revocation. Revocations shall be sent by postal or electronic mail to:
Bupa Privacy Office
17901 Old Cutler Road, Suite 400
Palmetto Bay, Florida 33157 USA
Privacyoffice@bupalatinamerica.com

n In the event that I am represented by a producer, I hereby authorize that person to review the information provided on this Claim Form.

I have reviewed and understand the content and purpose of this Acknowledgement and Authorization. By signing, I am confirming that the authorization
decisions noted above accurately reflect my wishes.

Policyholder’s signature Date

MM / DD / YY

Patient’s signature Date

(if 18 or older) MM / DD / YY

RESTRICTED-CONFIDENTIAL WHEN COMPLETED T&T_CF_BCA_V18.02