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CANCER
- Use claim form C101.
- Complete the section entitled "Claimant's Statement". Be sure to date and sign the blanks provided at the bottom of the form.
- A pathology report diagnosing cancer must accompany the first claim for that diagnosis of cancer. (The hospital or doctor will furnish this report at the patient's request.) If the diagnosis of cancer was made by clinical information instead of pathological means, the clinical evidence that established the diagnosis of cancer must be submitted.
- Submit completely itemized bills for hospitalizations, surgery, anesthesia, chemotherapy and radiation therapy, etc.
- For transportation benefits, a statement of the mileage from the employee's legal residence to the place of treatment should be obtained from the local law enforcement agency or ambulance service.
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DREAD DISEASE CLAIMS
- Use claim form C101.
- Complete the section entitled "Claimant's Statement". Be sure to date and sign in the blanks provided at the bottom of the form.
- The pathology report from tissue specimens, cultures and/or titers or other diagnostic studies that showed initial diagnosis of the dread disease must accompany the first claim.
- Submit the hospital bill that shows the number of days of confinement and charges.
- When your claim is received, we may request the hospital admission and discharge summaries from the hospital where you were confined.
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CANCER WELLNESS BENEFIT CLAIMS
- Use claim form C101.
- Complete the section entitled "Claimant's Statement". Be sure to date and sign in the blanks provided at the bottom of the form.
- The physician's itemized statement of services rendered must accompany the claim form. This is the walkout statement you receive from the doctor's office at the end of your appointment.
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