Claim Form Rev 102012 213 385

User Manual: 213-385

Open the PDF directly: View PDF PDF.
Page Count: 2

DownloadClaim Form Rev 102012 213-385
Open PDF In BrowserView PDF
SOUTHERN CALIFORNIA PIPE TRADES
HEALTH & WELFARE FUND

501 Shatto Place, 5th Fl., Los Angeles, CA 90020
(800) 595-7473 (213) 385-6161
Fax:(213) 487-3640 www.scptac.org

CLAIM
FORM

SOUTHERN CALIFORNIA PIPE TRADES
PENSIONERS & SURVIVING SPOUSES
HEALTH FUND

(For Active Participants
& Eligible Dependents)

(i) A new claim form is required once every calendar year.
(ii) A new claim form is required for each new injury.
(iii) This Claim Form is necessary for the Fund to determine eligibility for benefits. All questions must
be answered or Claim Form will be returned. This form will NOT be valid unless signed in Part V.
Failure to complete and sign this form will delay the processing of your claim.

PART I : PARTICIPANT & SPOUSE INFORMATION
SPOUSE

PARTICIPANT

(required whether or not spouse is patient)

NAME
First

Last

First

Last

SSN or
PARTICIPANT ID
(SSN only the last four
digits required)

DATE OF
BIRTH

ADDRESS

mm/dd/yy

mm/dd/yy

Street

Street

City

PHONE

State

(

)

Zip

-

City

(

State

)

Zip

-

EMPLOYER
NAME

EMPLOYER
ADDRESS

Street

Street

City

EMPLOYER
PHONE

(

State

)

Zip

-

City

(

State

)

Zip

-

PART II : PATIENT INFORMATION
PHONE

NAME
First

ADDRESS
(if different from
above)

Last

State

PATIENT MARITAL STATUS

Zip

SINGLE

)

-

RELATIONSHIP
TO
PARTICIPANT

(
(
(

) SELF
) SPOUSE
) DEPENDENT CHILD

PATIENT
GENDER

(
(

) MALE
) FEMALE

Street

City

(

MARRIED

DIVORCED

Printed

Southern California Pipe Trades Administrative Corporation
Page 1 of 2

CLAIM FORM
rev 102012

PART III : OTHER COVERAGE or BENEFITS
NO

Is the patient eligible for other coverage or benefits?
If YES, please provide, type of coverage:
NAME OF
POLICY HOLDER

Medical

First

POLICY HOLDER
EMPLOYER
INFORMATION

Dental

(skip to
PART IV)

Vision

YES
Others:_____________

Last

Name of policy holder Employer

POLICY
INFORMATION

Name of insurance group or plan number

(
Policy Account Number

)

-

Phone Number of insurance group or plan

PART IV : CLAIM INFORMATION
This claim is being
submitted for:

PERIODIC SUBMISSION
every calendar year
(skip to PART V)

NEW NON-WORK RELATED
INJURY OR ILLNESS
(complete the following)

NEW WORK RELATED
INJURY OR ILLNESS
(complete the following)

DESCRIPTION
of Injury or Illness
Attach additional pages if necessary.

HOW it occurred.
Describe sequence of
events and provide a
complete description of
Injury.
(include information of
other parties involved)

WHERE
(address of location)

WHEN
(date & time)

PART V : AUTHORIZATION
I/We hereby certify that the foregoing statements, including any accompanying statements, are true, correct and complete to the best of my/our knowledge. I/We hereby authorize the attending physician or any hospital to furnish and disclose to the Southern California Pipe Trades Health & Welfare Fund
or its agents all records and information concerning my physical condition that are within their possession or knowledge. I/We further authorize the Health
& Welfare Fund to use or disclose the information contained in its claim files in whatever way deemed necessary for the purpose of determining the reasonableness of any of the expenses submitted herewith or the propriety of this claim. I/We also authorize any Union, Trust Fund, Employer or Insurance
Carrier to furnish the Southern California Pipe Trades Health & Welfare Fund with information regarding benefits to which I/we may be entitled.

X
X

Participant’s Signature

Date

Patient’s Signature (Not required if under 18 years of age)

Date

Southern California Pipe Trades Administrative Corporation
Page 2 of 2

CLAIM FORM
rev 102012
Printed
Source Exif Data: 
File Type                       : PDF
File Type Extension             : pdf
MIME Type                       : application/pdf
PDF Version                     : 1.6
Linearized                      : Yes
Author                          : allison
Create Date                     : 2014:01:21 08:26:49-08:00
Modify Date                     : 2014:01:21 08:28:19-08:00
XMP Toolkit                     : Adobe XMP Core 4.2.1-c043 52.372728, 2009/01/18-15:08:04
Creator Tool                    : PScript5.dll Version 5.2.2
Metadata Date                   : 2014:01:21 08:28:19-08:00
Format                          : application/pdf
Title                           : Claim Form rev 102012.pdf
Creator                         : allison
Producer                        : Acrobat Distiller 9.5.5 (Windows)
Document ID                     : uuid:c9c1370c-b247-4586-b332-1c9914f61ed8
Instance ID                     : uuid:b037f89c-371c-49b0-a154-846901d509fe
Page Count                      : 2
EXIF Metadata provided by EXIF.tools

Navigation menu