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Medical
Claim Forms
To request reimbursement
of incurred medical expenses or to seek preapproval of medical care,
you must submit a claim or preapproval request to your health
care insurance first. For detailed information, review these
instructions.
Submit
all charges first to the health insurance plans in which you have
coverage. Only the amounts not covered by insurance can be claimed
through the Disability Board.
All
completed claims need to be received in the Board office by the
second Wednesday of the month in which you wish them reviewed.
- Form
5 / Form
5 (fill-in)
(employer’s form). This form needs to be completed by the
employer and attached to your claim before it is submitted to
the Board for review.
- Form
6
/ Form
6 (fill-in)
(LEOFF-1 member's form). Every medical and alternative health
care claim must have a Form 6 completed by you. Fill in all blanks,
including a list of service dates, name of medical provider and
total dollar amount of charges left after insurance.
- Form
7 / Form
7 (fill-in)
(health care provider's form). All medical/health care/vision
claims need Form 7 as documentation from the physician or therapist
(omitted for long-term care, assisted living, in-home care and
hospice). Ask your physician or health care provider to complete
all sections, sign and date the form, and return it to you.
- Form
8 / Form
8 (fill-in)
(treatment plan). A provider may use this form in place of a written
treatment plan for the following treatments (either a written
treatment plan or Form 8 is required for all of these services):
acupuncture/acupressure, massage therapy, smoking cessation,
mental health, chiropractic care and substance abuse.
- Form
9 / Form
9 (fill-in)
(nursing home/assisted care facility form). This form replaces
Form 7 and Form 8 when applying for reimbursement of costs incurred
for nursing home or assisted care. This form needs to be completed
by the responsible family member/legal representative as well
as by the director of nursing and medical director or primary
physician.
- Form
10A / Form
10A (fill-in) ;
Form
10B / Form
10B (fill-in) ;
Form 10C
/ Form
10C (fill-in)
(home health
care forms). These
forms replace forms 7, 8 and 10 when applying for reimbursement
of costs for in-home care. Please follow the directions on each
form when submitting your claim for reimbursement..
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