UHC Accident Wellness Claim Form

(Rev 05/2021)

UA 1.2020

WELLNESS BENEFIT CLAIM FORM

(Critical Illness Insurance)

Page 1 of 4

Policy or Certificate Number

EMPLOYEE’S INFORMATION

Employee’s Full Name (Last, First, Middle Initial) Employee’s Date of Birth

Employee’s Address City State, Zip Code Telephone

Name of Employer:

PATIENT INFORMATION

Full Name (Last, First, Middle Initial) Social Security Number

Relationship:

Primary Policyholder

Spouse

Date of Birth

Sex:

Male

Female

WELLNESS EXAM

Some of the tests listed below may not be covered under the Wellness Benefit of your Policy. Please check your Policy for a

list of covered wellness procedures.

Wellness Exam Date:______________________

Colonoscopy

Virtual Colonoscopy

Stress Test on a b

icycle or

treadmill

Blood Test for T

riglycerides

Serum Cholesterol

est for

level of HDL and LDL

hermography

Fasti

ng blood g

lucose test

Bone

Marrow T

esting

Breast Ultrasound

Mammography

CA 15-3

(blood tes

t for breast

cancer)

CA125 (bloo

d t

est for ovarian

cancer)

A (blood test for colon

cancer)

Chest X-ray

Hemoccult

stool

analy

sis

ear

(

d t

te cancer)

Serum Pr

otein

Electro

phoresis

(blood

test

for myeloma)

Flexible S

igmoidoscopy

PHYSICIAN INFORMATION

Name: Phone Number:

Address:

City: S

tate: Zip

PLEASE ATTACH ITEMIZED BILLS

PO Box 7466 Portland ME 04112-7466 Tel 800 539 0038 Fax 888-505-8550

Unsecured E-mail: [email protected]

Date:

_______________________________________

t to UnitedHealthcare Specialty Benefits, at the followi

_______________________________________________

DISCLOSURE AUTHORIZATION – Supplemental Health

TO BE COMPLETED BY EMPLOYEE

Participant’s Name

I AUTHORIZE: any doctor, physician, healer, health care practitioner, hospital, clinic, other medical facility,

professional, or provider of health care, medically related facility or association, medical examiner, pharmacy,

pharmacy benefit manager, insurance company, health maintenance organization or similar entity to provide access

to or to give UnitedHealthcare Insurance Company (Company) or the Plan Administrator or their employees and

authorized agents or authorized representatives, any medical and non-medical information or records that they may

have concerning my health condition, or health history, or regarding any advice, care or treatment provided to me.

This information and/or records may include, but is not limited to: cause, treatment diagnoses, prognoses,

consultations, examinations, tests, prescriptions, or advice regarding my physical or mental condition, or other

information concerning me. This may also include, but is not limited to, information concerning: mental illness,

psychiatric, drug or alcohol use, and also HIV related testing, infection, illness, and AIDS (Acquired Immune

Deficiency Syndrome). If my Plan Administrator sponsors both a supplemental health plan underwritten or

administered by the Company and a medical plan of any type written by another UnitedHealth Group Company, the

information and records described in this form may also be given to any UnitedHealth Group Company which

administers such medical or supplemental health benefits for the purpose of evaluating any claim that may be

submitted by me or on my behalf for benefits and for administering any feature described in the plan. This information

may also be extracted for use in audits or for statistical purposes.

I AUTHORIZE: any financial institution, accountant, tax preparer, insurance company or reinsurer, consumer reporting

agency, insurance support organization, Claimant’s agent, employer, group policyholder, benefit plan administrator, or

governmental agency to give the Company or the Plan Administrator or their employees and authorized agents, or

authorized representatives, any information or records that they have concerning me, employee/employment records,

earnings or finances, prior claims files and claim history, work history and work related activities.

I UNDERSTAND: the informat

ion obtained will be included as part of the proof of claim and will be used to determine

eligibility for claim benefits, any amounts payable and to administer any other feature described in the plan with

respect to the Claimant. This authorization shall remain valid and apply to all records, information and events that

occur over the duration of the claim, but not to exceed 12 months. A photocopy of this form is as valid as the original

and I or my authorized representative may request one. I or my representative may revoke this authorization at any

time as it applies to future disclosures, by notifying the Company in writing. The information obtained will not be

disclosed to anyone EXCEPT: (a) reinsuring companies; (b) the Medical Information Bureau, Inc., which operates

Health Claim Index (HCI); (c) fraud or overinsurance detection bureaus; (d) anyone performing business, medical or

legal functions with respect to the claim or the plan; (e) for audit or statistical purposes; (f) as may be required or

permitted by law; or (g) as I may further authorize. A valid authorization or court order for information does not waive

other privacy rights.

If my medical i

nformation contains information regarding drugs or alcohol abuse, I understand that my records may be

protected under federal (42 CFR Part 2) and some state laws. To the extent permitted under law, I can ask the party

that disclosed information to the Company to permit me to inspect and copy the information it disclosed. I understand

that I can refuse to sign this disclosure authorization; however, I understand that if I do so, the Company may deny my

claim for benefits pursuant to the plan. The use and further disclosure of information disclosed hereunder may not be

subject to the Health Insurance Portability and Accountability Act (HIPAA).

Signature of Claimant or

Claim

ant’s Authorized Representative:

_____________________________________ _____

_____________

PLEASE SIGN AND DATE

IN INK

Relationship, if other than Claimant:

Please fax, email

or mail this statemen ng locations:

Fax: 888 505 8550 Unsecured E-mail: FPCustomerSuppor[email protected] Mail: PO Box 7466 Portland ME 04112-7466

(Rev 10/2020)

UA 10.2020

FRAUD WARNING NOTICES: (Please review notice that applies in your state)

For claimants in Alabama:

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly

presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines,

or confinement in prison, or any combination thereof

For claimants in Alaska:

A person who knowingly and w

ith intent to injure, defraud, or deceive an insurance company files a c laim containing

false, incomplete, or misleading information may be prosecuted under state law.

For claimants in Arizona:

For your protection Arizona law requires the following statement to appear on this form. Any

person who knowingly presents a false or fraudulent claim for payment of a loss is subject to

criminal and civil penalties.

For your protection California law requires the following to appear on this form:

Any person who knowingly presents a false or fraudulent claim for the payment of a loss is

guilty of a crime and may be subject to fines and confinement in state prison.

For claimants in Colorado:

It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for

the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial

of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides

false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or

attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance

proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

For claimants in Connecticut:

Any person who knowingly presents false information in an application for insurance or life settlement contract is

guilty of a crime and may be subject to fines and confinement in prison.

For claimants in Delaware

Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim

containing any false, incomplete or misleading information is guilty of a felony.

For claimants in District of Columbia:

WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the

insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny

insurance benefits if false information materially related to a claim was provided by the applicant.

For claimants in Florida:

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an

application containing any false, incomplete, or misleading information is guilty of a felony of the third degree

For claimants in Hawaii:

For your protection, Hawaii law requires you to be informed that presenting a f raudulent claim for payment

of a l oss or benefit is a c rime puni shable by fines or imprisonment, or both.

For claimants in Idaho

Any person who

knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim

containing any false, incomplete, or misleading information is guilty of a felony.

For claimants in Indiana:

A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false,

incomplete, or misleading information commits a felony

For claimants in Kansas:

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an

application containing any false, incomplete, or misleading information may be guilty of fraud as determined by a

court of law.

For claimants in Kentucky:

Any person who knowingly and with intent to defraud any insurance company or other person files a statement of

claim containing any materially false information or conceals, for the purpose of misleading, information concerning

any fact material thereto commits a fraudulent insurance act, which is a crime.

(Rev. 06/18)

FRAUD WARNING NOTICES: (Please review notice that applies in your state)

For claimants in Maine:

It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the

purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

For claimants in Maryland:

Any person who knowingly or willfully presents a false or fraudulent claim for payment for a loss or benefit or who

knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be

subject to fines and confinement in prison.

For claimants in Minnesota:

A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

For claimants in New Hampshire:

Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of claim

containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance

fraud, as provided in RSA 638:20.

For claimants in New Jersey:

Any person who knowingly files a statement of claim containing any false or misleading information is subject to

criminal a nd civil p enalties.

For claimants in New Mexico:

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly

presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and

penalties.

For claimants i n Ohio:

Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an

application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

For claimants i n Oklahoma:

WARNING: Any person who knowingly, and with intent to injure, defraud or deceive and insurer, makes any claim

for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a

felony.

For claimants i n Oregon:

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly

presents false information in an application for insurance may be guilty of a crime and may be subject to fines and

confinement in prison.

For claimants i n Pennsylvania:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for

insurance or statement of claim containing any materially false information or conceals for the purpose of

misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime

and subjects such person to criminal and civil penalties.

For claimants i n Tennessee and Washington:

It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the

purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

For claimants i n Texas:

Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and

may be subject to fines and confinement in state prison.

For claimants i n Vermont:

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an

application containing false, incomplete, or misleading information may be guilty of a crime.

For claimants i n Virginia:

Any person who knowingly, and with intent to injure, defraud, or deceive any insurer, makes any claim for the

proceeds of an insurance policy containing false, incomplete, or misleading information may have violated state law.

For claimants i n All Other States:

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or know

ingly

presents false information in an application for insurance is guilty of a crime and may be subject to

fines and

confinement in prison.

(Rev. 06/18)