Fillable Printable Claim for Hospital and Other Medical Expenses - the World Bank Group
Fillable Printable Claim for Hospital and Other Medical Expenses - the World Bank Group
Claim for Hospital and Other Medical Expenses - the World Bank Group
PART II - TO BE COMPLETED BY ATTENDING PHYSICIAN (in lieu of itemized bill)
PART I - TO BE COMPLETED BY STAFF MEMBER OR RETIRED STAFF MEMBER (hereinafter: staff member) OR PATIENT IF COVERED SEPARATE FROM STAFF MEMBER
THE WORLD BANK GROUP
CLAIM FOR HOSPITAL AND OTHER MEDICAL EXPENSES
1. Patient's Name (Last, First, M.I.)
892 (6-2005)
4
Month
If illness or injury occured while at work, contact the Workers Compensation Insurance Representative, ext. 30807, BEFORE filling out this form.
Self
2. Patient's Relationship to Staff Member
Spouse/DP Child Dependent Parent
3. Patient's Birthdate
Day Year
4. Sex
M F
5. If claim is for son/daughter, was a Dependency (Tax Equivalency) Allowance payable at the time the expense was incurred?
Yes No. If No, please answer questions A and B below.
A. Is he/she married? Yes No B. If over 18, is he/she a full time student & dependent upon you for support & maintenance? Yes No
6. Staff Member's (or Surviving Spouse's) Name (Last, First, M.I.)
IF NOT PATIENT
7. Staff Member's (or Surviving Spouse's) Birthdate
IF NOT PATIENT
8. UPI No.
9. Nature of illness, injury or service
10. If claim is for accidental injury, enter date and indicate where and how it occurred 11. Is claim for second surgical opinion?
Yes No
12. Is patient, other than
staff member, employed?
Yes
No
If Yes, Employee name?
13. Name and Address of Employer in Item 12.
14. Is patient covered by another group, student, government (e.g. Medicare) or employment related Medical Plan?
Yes No, If Yes, enter:
Medical Plan Name Group No. Name & Address of Carrier
I authorize the release to the World Bank Group Medical Insurance Plan administrator, to the World Bank Group or their representative, any information including medical,
employment and benefit information required for claim processing or plan administration. Such information shall be released directly to the World Bank Group only in
circumstances where fraud or misconduct is believed to have occurred. This authorization to release information is valid for two years after the date signed. A copy of this
authorization shall be as valid as the original. If the staff member is incapacitated or deceased, the Personal Representative or next of kin must sign.
Patient's Signature (Parent/Guardian, if minor;
leave blank if staff member)
Staff Member's Signature
I certify that the statements here and attached are complete and accurate. As the patient, I authorize the release of information as described above.
Date
Date
Keep a copy of completed form for your records
15. Physician's Name
16. Mailing Address (Street, City, State, ZIP)
17. Is treatment result of occupational illness or injury?
Yes No. If Yes, enter brief description and dates
18. Date symptoms first appeared or accident happened?
19. Physician's S.S.N. or T.I.N. 20. Physician's License No. 21. Physician's Telephone No. 22. Date you were first consulted on this condition?
23. Diagnosis and current condition
24. Has patient ever had same or similar condition? Yes No, If Yes, indicate when and describe
25. Is patient still under your care for this condition? Yes No
Date of Service
26. I certify that the procedures as
indicated by date have been completed
Return completed form to:
Aetna/World Bank MIP Claims P.O. Box 14199 Lexington, KY 40512-4199 USA OR via internal mail to MIP claims MSN MC-C3-309.
Signature Date
Place ICD-9 Code Description Charge
