INSTRUCTIONS: SOUTHLAND NATIONAL INDEMNITY AND CANCER CLAIM FORM
Alabama public employees who are treated in a hospital or for cancer use the claim form discussed in this article to file a claim for coverage with Southland Benefits. This document can be obtained from the website of the Retirement Systems of Alabama.
Southland National Indemnity And Cancer Claim Form Step 1: Enter the subscriber's name in box 1.
Southland National Indemnity And Cancer Claim Form Step 2: Enter the subscriber's contract number in box 2.
Southland National Indemnity And Cancer Claim Form Step 3: Enter the subscriber's home address in box 3.
Southland National Indemnity And Cancer Claim Form Step 4: Enter the patient's name in box 4.
Southland National Indemnity And Cancer Claim Form Step 5: Enter the patient's date of birth in box 5 and their age in box 6.
Southland National Indemnity And Cancer Claim Form Step 6: Indicate the patient's sex with a checkmark in box 7.
Southland National Indemnity And Cancer Claim Form Step 7: Indicate the patient's relationship to the subscriber with a checkmark in box 8.
Southland National Indemnity And Cancer Claim Form Step 8: Enter the subscriber's home and work phone numbers in box 9.
Southland National Indemnity And Cancer Claim Form Step 9: In box 10, provide a written summary of the type of illness or injury, or the doctor's diagnosis.
Southland National Indemnity And Cancer Claim Form Step 10: Enter the physician's name and address, the name of the hospital if confined, the date of admission and discharge, the date the accident or the sickness began, the date on which the first treatment was administered, and indicate whether the condition was related to an accident or illness. Specify the type of accident or illness.
Southland National Indemnity And Cancer Claim Form Step 11: Sign and date the top half of the form.
Southland National Indemnity And Cancer Claim Form Step 12: Give the form to the supervising doctor. They will fill out the attending physician's statement and return the form to you.
Southland National Indemnity And Cancer Claim Form Step 13: Obtain an itemized copy of the hospital bill and attach it to the claim form.
Southland National Indemnity And Cancer Claim Form Step 14: Mail the form and bill to Southland Benefits Administration via the address given on the second page.
