International Medical Expense Claim Form
Please complete the form below to claim your medical expenses incurred internationally.
Full Name
First Name
Last Name
Policy Number
Date of Treatment
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Country of Treatment
Please Select
United States
Canada
United Kingdom
Australia
Germany
France
Japan
China
India
Other
Medical Provider Name
Description of Medical Treatment
Total Amount Claimed (in USD)
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