Forms

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.

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.

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.

Claim Form

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 included in the Claim Information Package.

Claim Information Package

The claim information package contains the documents to explain the claim filing process and the forms you may need
when filing a new claim.

Claimant Care Needs Assessment Form

This form is required to verify the needs of the claimant. It is to be completed by a licensed health care practitioner.

Continued Monthly Residence (CMR) Form

The CMR form must be completed for facility claims by an authorized representative of the facility on a monthly basis and submitted with the bill(s) after the end of each month.

Direction to Pay

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.

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.

Home Health Progress Notes

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 Healthcare Checklist

This form is designed to help you stay organized while submitting a new home health care claim. This checklist does not
need to be returned.

How to file a claim

This document outlines the forms that are necessary to file a new claim under your SHIP long-term care policy and
explains the time frames associated with filing a new claim.

Nursing Facility Checklist

This form is designed to help you stay organized while submitting a new nursing facility claim. This checklist does not
need to be returned.

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.