Medical Discharge Benefits Claim Form
Submit your medical discharge benefits claim and supporting details for review.
Claimant Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Mailing Address
*
Preferred Contact Method
*
Phone
Email
Mail
Medical Discharge Claim Details
Hospital or Facility Name
*
Discharge Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Claim Type
*
Discharge reimbursement
Post-discharge care benefit
Travel/transport benefit
Other medical discharge benefit
Reason for Claim
*
Documentation and Declaration
Supporting Documents
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Declaration and Authorization
*
I confirm that the information provided is complete and accurate, and I authorize review of this medical discharge claim
No, I do not authorize review of this claim
Submit Claim
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