Health Insurance Claim Process Checklist Form
Use this checklist to ensure all required information and documents are ready before submitting your health insurance claim.
Claimant/Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Insurer Name
*
Policy Number
*
Type of Claim/Event
*
Please Select
Hospitalization
Outpatient Treatment
Accident
Routine Checkup
Surgery
Other
Date of Incident or Treatment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Required Documentation Checklist
*
Completed claim form
Medical reports or discharge summary
Hospital/clinic bills and receipts
Doctor’s prescription(s)
Investigation/lab reports
Policy document copy
Photo ID of claimant/patient
Other supporting documents
Other
List any missing or pending documents/items
Is the claim ready for submission?
*
Yes, all items are complete
No, some items are missing
Submit Checklist
Should be Empty: