Forms
Bank Draft
The option is available to have your Long Term Care policy premiums deducted directly from your checking or savings account. Please follow the instructions on the form if you would like your policy premiums deducted automatically.
Authorization to release medical information
Due to HIPAA regulations we are unable to release your personal information without your authorization. If you would like to grant access to your policy information to someone else, please print, complete and mail the attached form to our office.
Claim Form (for use by policyholders with a policy formerly owned by Conseco Senior Health Insurance Company, American Travelers Life Insurance Company)
To submit a request for an eligibility determination, a claim form and additional information is required to initiate this process. Please read the "To File a Claim" instructions with the claim form.
Claim Form (for use by policyholders with a policy formerly owned by Conseco Senior Health Insurance Company, Transport Life Insurance Company and Continental Life Insurance Company)
To submit a request for an eligibility determination, a claim form and additional information is required to initiate this process. Please read the "To File a Claim" instructions with the claim form.
Home Health Care Daily Progress Notes
(for use by policyholders with a policy formerly owned by Conseco
Senior Health Insurance Company, American Travelers Life Insurance Company)
This form is provided for your convenience in the event
your home health care provider does not have their own daily progress notes or billing forms.
Home Health Care Daily Progress Notes
(for use by policyholders with a policy formerly owned by Conseco Senior Health Insurance Company,
Transport Life Insurance Company and Continental Life Insurance Company)
This form is provided for your convenience in the event your home health care
provider does not have their own daily progress notes or billing forms.
HIPAA Claims Processing
It may be necessary for us to request additional information to reach an eligibility determination. By completing and submitting this form to us you give us authorization to obtain personal information, including health information, from your physicians, medical practitioners, hospitals, clinics, etc. If this form is not submitted with your claim form it may delay our handling of your claim.
Direction to Pay (for use by policyholders with a policy formerly owned by Conseco Senior Health Insurance Company, American Travelers Life Insurance Company)
If you choose to assign your long term care insurance benefits to a covered provider you must submit the Direction to Pay form to SHIP. The Direction to Pay form is provided as a convenience to our policyholders and their care providers to assign benefits to the care provider, but not the rights under the policy.
Direction to Pay (for use by policyholders with a policy formerly owned by Conseco Senior Health Insurance Company, Transport Life Insurance Company and Continental Life Insurance Company)
If you choose to assign your long term care insurance benefits to a covered provider you must submit the Direction to Pay form to SHIP. The Direction to Pay form is provided as a convenience to our policyholders and their care providers to assign benefits to the care provider, but not the rights under the policy.
W-9 Request for Taxpayer Identification Number and Certification
If you choose to assign your long term care insurance benefits to your covered provider, this form is required from your covered provider.
Affidavit and Indemnity Agreement
This form is required to recognize and work with deponents as the sole, legal, equitable, and unrestricted heirs to the deceased's estate.
Facility Cognitive Questionnaire
Additional information may be required for eligibility determinations. The form must be completed by the nursing staff of your long term care facility.
Re-Servicing Claim Form (for use by policyholders with a policy formerly owned by Conseco Senior Health Insurance Company, American Travelers Life Insurance Company)
To submit a request for an eligibility determination, a claim form and additional information is required to initiate this process. Please read the "To File a Claim" instructions with the claim form.
Re-Servicing Claim Form (for use by policyholders with a policy formerly owned by Conseco Senior Health Insurance Company, Transport Life Insurance Company and Continental Life Insurance Company)
To submit a request for an eligibility determination, a claim form and additional information is required to initiate this process. Please read the "To File a Claim" instructions with the claim form.