FAMILY HERITAGE LIFE INSURANCE COMPANY OF AMERICA

P.O. Box 470608, Cleveland, OH 44147, (440) 922-5151

FORM C15CLM-ST

SIDE 1

CANCER AND ICU CLAIM FORM

Instructions: 1. Have the claimant answer all questions, sign and date SIDE 1.

2. Have the treating physician complete SIDE 2.

If filing a cancer claim submit one claim form for each hospital admission along with all itemized hospital bills,

doctor bills, surgery bills from the surgeon with an attached pathology report, and chemotherapy/radiation bills.

If filing an intensive care claim submit one claim form for each hospital admission along with a copy of the

itemized hospital bill listing the intensive care charges and an ambulance bill, if applicable.

1. Policyowner’s Name: 2. Policy #:

3. Claimant’s Name: 4. Social Security No.:

5. Address: 6. Phone number: ( )

7. Date of Birth:

8. Relationship to Policyowner: 9. Describe illness/injury:

10. Date first consulted physician: 11. Date diagnosed:

12. Have you ever had this condition before?

 YES  NO

If YES, when?

13. List all treating physicians. Include name and phone number:

14. Name and

hone number of famil

sician: 15. Name and

hone number of other

sicians:

16. If hospitalized, when? From to Hospital phone: ( )

17. Hospital name:

city state

18. Have you ever filed a claim for this condition with Family Heritage?

 YES  NO

IMPORTANT NOTICE: Any person who, knowingly facilitates a fraud or has intent to defraud an insurer,

or submits an application or files a claim containing false or deceptive statements may be guilty of

insurance fraud.

AUTHORIZATION MUST BE SIGNED BEFORE CLAIM CAN BE PROCESSED

I hereby authorize any legally licensed physician, medical practitioner, hospital, clinic or other medical or

medically related facility, pharmacy benefit manager or prescription data base, including prescription drug

records, insurance company, or MIB, Inc. to furnish to Family Heritage Life Insurance Company of America or its

representative or permit said insurance company or its representative to review for the purpose of evaluating

claims for benefits any information with respect to any illness or accident, medical history or medical records.

understand that a photostatic copy of this authorization shall be considered as valid as the original and shall

remain valid 30 months from the date signed. I further understand that I or my authorized representative may

request a copy of this authorization.

Signed Date

Claimant, Parent (If Child) or Executor

IF THE CLAIMANT IS UNABLE TO PROVIDE A SIGNATURE, PLEASE INCLUDE A COPY OF A POWER OF

ATTORNEY, LETTER OF EXECUTOR AND/OR DEATH CERTIFICATE

SUPPLEMENTAL PHYSICIAN’S STATEMENT TO BE COMPLETED BY TREATING PHYSICIAN

FORM C15CLM-ST

SIDE 2

Patient’s Name________________________________ Policy Number: __________________________

Cancer Claims:

1. When was any type of cancer first diagnosed? Diagnosis code(s):

2. When did you first consult the most recent condition?

3. Is this a recurrence of a previous cancer?

 YES  NO

If YES, give date of recurrence:

List date of last known cancer treatment: Type of treatment:

4. List name of referring physician: Phone number:

5. Was patient hospitalized solely due to this condition?

 YES  NO

If YES, list name & address of facility:

Date admitted: Date discharged:

6. If outpatient, list dates of service:

7. What services were rendered during the period listed above?

 biopsy

 surgery

 chemotherapy

 radiation

 hospice

 skilled nursing

8. Please provide any applicable surgery CPT procedure code(s):

9. Has the patient ever been diagnosed with AIDS/ARC?

 YES  NO

If YES, when?

Intensive Care Claims:

1. Has the patient ever been diagnosed with or treated for a heart attack, heart disease or stroke?  YES  NO

If YES, date of first diagnosis: If YES, date of first treatment:

2. List reason for hospitalization:

3. Was the patient ever diagnosed with the above condition prior to this admission?

 YES  NO

If YES, when?

4. Was

atient hos

italized solel

due to this condition?  YES  NO

If YES, list name & address of facility:

Date admitted: Date discharged:

5. List specific dates of intensive care confinement:

6. Has the patient ever been diagnosed with AIDS/ARC?

 YES  NO

If YES, when?

Physician’s Information:

Physician’s Name:

Specialty:

Address and phone number:

Completed by (please print): Position/Title:

Physician’s Signature:

Date: