Southland National Vision Claim Form

INSTRUCTIONS: SOUTHLAND VISION CLAIM FORM

Alabama public employees who are enrolled with Southland Benefit Solutions health insurance use the vision claim form discussed in this article to file for coverage for a vision health appointment. This document can be obtained from the website of Southland Benefit.

Southland Vision Claim Form Step 1: The top half of the form is to be completed by you. In box 1, indicate with a check mark whether you are enrolled with Medicare, Medicaid, a group health plan or other. Give the number of your plan in box 1a.

Southland Vision Claim Form Step 2: Enter the patient's name in box 2. Enter the last name first, followed by the first name and middle initial.

Southland Vision Claim Form Step 3: Enter the patient's birth date in box 3.

Southland Vision Claim Form Step 4: Enter the insured's name in box 4.

Southland Vision Claim Form Step 5: Enter the patient's address in box 5.

Southland Vision Claim Form Step 6: Indicate the patient's relationship to the insured with a checkmark in box 6.

Southland Vision Claim Form Step 7: Enter the insured's street address, city, state, zip code and telephone number including area code in box 7.

Southland Vision Claim Form Step 8: Indicate the patient's status with a checkmark in box 8. Choose from "single," "married," "other," "employed," "full-time student" and "part-time student" as appropriate.

Southland Vision Claim Form Step 9: In boxes 10 through 10d, give the insured's group policy or FECA number, employer's or school name, insurance plan or program name, and indicate if there is another health benefit plan. If so, complete boxes 9 through 9d.

Southland Vision Claim Form Step 10: The patient or an authorized person should sign box 11.

Southland Vision Claim Form Step 11: The insured or an authorized person should sign box 12.

Southland Vision Claim Form Step 12: The remainder of the form should be submitted to the office of the vision physician or supplier in question. This office will be responsible for completing and submitting the form.

Southland Vision Claim Form Step 13: This form must be submitted by the physician or supplier to Southland within 365 days of the date of service. The address to which this form should be submitted can be found at the top of the page.

Southland National Dental Claim Form

INSTRUCTIONS: SOUTHLAND DENTAL CLAIM FORM

Alabama public employees who have dental insurance from Southland Benefit Solutions use the dental claim form discussed in this article after having a dental appointment. This document can be obtained from the website maintained by Southland Benefit.

Southland Dental Claim Form Step 1: In box 1, check all applicable boxes concerning the type of transaction this claim covers.

Southland Dental Claim Form Step 2: In box 2, enter the predetermination/preauthorization number if applicable.

Southland Dental Claim Form Step 3: In box 3, give the name, address, city, state and zip code of your insurance company or dental benefit plan.

Southland Dental Claim Form Step 4: Indicate with a checkmark in box 4 whether you have other dental or medical coverage. If no, skip to box 12.

Southland Dental Claim Form Step 5: If you have other medical or dental coverage, give the name of policyholder or subscriber in box 5, enter their date of birth in box 6, check the box next to their gender in box 7, give their policy or subscriber ID in box 8, the plan or group number in box 9, indicate the patient's relationship to the policyholder in box 10 with a checkmark, and give the company or benefit plan's name, address, city state and zip code in box 11.

Southland Dental Claim Form Step 6: In box 12, enter the policyholder or subscriber name, street address, city, state and zip code for the policy listed in box 3.

Southland Dental Claim Form Step 7: In box 13, give their date of birth.

Southland Dental Claim Form Step 8: In box 14, indicate their gender with a checkmark.

Southland Dental Claim Form Step 9: In box 15, give their policy or subscription identification number.

Southland Dental Claim Form Step 10: In box 16, give the plan or group number.

Southland Dental Claim Form Step 11: Give the employer name in box 17.

Southland Dental Claim Form Step 12: Provide all information requested about the patient in boxes 18 through 23.

Southland Dental Claim Form Step 13: Boxes 24 through 35 should be filled out by the office which performed the services in question.

Southland Dental Claim Form Step 14: The patient or guardian, as well as the subscriber, should sign and date the left hand bottom corner of the page where indicated.

Southland National Indemnity and Cancer Claim Form

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.

MedImpact Prescription Drug Claim Form

INSTRUCTIONS: MEDIMPACT PRESCRIPTION DRUG CLAIM FORM

Alabama public employees enrolled in the PEEHIP health insurance program use the prescription drug claim form discussed in this article to obtain coverage for their prescription drug purchases. This document can be obtained from the website of the Retirement Systems of Alabama.

MedImpact Prescription Drug Claim Form Step 1: The first section requires information about the primary member or cardholder. In the first two boxes, give their ID number and full name.

MedImpact Prescription Drug Claim Form Step 2: In the next three lines, provide the name of the health plan or insurance, the member's daytime phone number, and the member's evening phone number.

MedImpact Prescription Drug Claim Form Step 3: In the next four boxes, provide the member's street address, city, state and zip code.

MedImpact Prescription Drug Claim Form Step 4: The next section should only be filled out if the patient is not the same as the primary member or cardholder. In the first two boxes, enter the patient's name and date of birth.

MedImpact Prescription Drug Claim Form Step 5: Indicate the patient's relationship to the primary member or cardholder with a checkmark.

MedImpact Prescription Drug Claim Form Step 6: Enter the patient's street address, city, state and zip code in the next four boxes.

MedImpact Prescription Drug Claim Form Step 7: If you have any other coverage, enter its name.

MedImpact Prescription Drug Claim Form Step 8: If you have worker's compensation, stop filling out this form and submit your claims to your employer.

MedImpact Prescription Drug Claim Form Step 9: The next section requires details about all prescriptions relevant to this claim. You may either complete this section yourself and submit it with supporting prescription labels and receipts or have your pharmacist complete this section.

MedImpact Prescription Drug Claim Form Step 10: The claimant should sign the form where indicated at the top of the first page.

MedImpact Prescription Drug Claim Form Step 11: The final section concerns compound prescriptions and can only be completed by a pharmacist.

MedImpact Prescription Drug Claim Form Step 12: When submitting this form, it must be accompanied the original prescription label or receipt. Copies are not acceptable. Submit to the claim and prescription labels or receipts to the address at the top of the first page.

Health Insurance and Optional Enrollment Application

INSTRUCTIONS: ALABAMA HEALTH INSURANCE AND OPTIONAL ENROLLMENT APPLICATION

Alabama public education employees who wish to enroll in the state's health insurance plan known as PEEHIP do so using the form discussed in this article. This document can be obtained from the website of the Retirement Systems of Alabama.

Alabama Health Insurance And Optional Enrollment Application Step 1: Indicate with a check mark whether you are an active member or retired.

Alabama Health Insurance And Optional Enrollment Application Step 2: The first section concerns subscriber information. Enter your Social Security number, full name, mailing address, date of birth, home and work phone numbers, gender, marital status, the name of your employer and school system, your email address and date of employment.

Alabama Health Insurance And Optional Enrollment Application Step 3: Indicate with a check mark whether you or your spouse have made use of tobacco products within the last 12 months.

Alabama Health Insurance And Optional Enrollment Application Step 4: The next section concerns the type of coverage you are seeking. Indicate with a check mark whether you are applying for hospital/medical coverage, supplemental hospital/medical coverage, or a VIVA health plan. If the latter, indicate with a check mark whether you are seeking it as a single person or for a family.

Alabama Health Insurance And Optional Enrollment Application Step 5: Indicate with check marks all additional optional coverages you are seeking and enter your requested effective date.

Alabama Health Insurance And Optional Enrollment Application Step 6: The next section requires anyone seeking family coverage to document their dependents. Enter each dependent's name, Social Security number and date of birth. Indicate their gender and relationship to you with check marks.

Alabama Health Insurance And Optional Enrollment Application Step 7: The next section is to be completed if seeking PEEHIP Supplemental coverage or if you or your dependents currently have other group health, dental or vision coverage in effect.

Alabama Health Insurance And Optional Enrollment Application Step 8: The next section must be completed if you or your dependents are eligible for Medicare.

Alabama Health Insurance And Optional Enrollment Application Step 9: The next section is only for completion by PEEHIP members who retired after September 30, 2005.

Alabama Health Insurance And Optional Enrollment Application Step 10: Sign and date the bottom of the form.

Health Insurance and Optional Status Change

INSTRUCTIONS: ALABAMA HEALTH INSURANCE AND OPTIONAL STATUS CHANGE

Alabama public education employees who are already enrolled in the state insurance program known as PEEHIP can use the form discussed in this article to make changes to their insurance coverage, as well as to certify or change their tobacco usage status. This document can be obtained from the website maintained by the Retirement Systems of Alabama.

Alabama Health Insurance And Optional Status Change Step 1: Indicate with a check mark whether you are an active or retired member.

Alabama Health Insurance And Optional Status Change Step 2: The first section requires information about the subscriber. Enter your Social Security or PID number, full name, date of birth and daytime phone number. Indicate your marital status with a check mark.

Alabama Health Insurance And Optional Status Change Step 3: Indicate with check marks whether you or your spouse have used tobacco in the last 12 months.

Alabama Health Insurance And Optional Status Change Step 4: If you have changed your name or employers, give your new name and/or date of employment transfer.

Alabama Health Insurance And Optional Status Change Step 5: In the next section, indicate with check marks the changes you are requesting to be made.

Alabama Health Insurance And Optional Status Change Step 6: Enter the date you are requesting that the changes take effect.

Alabama Health Insurance And Optional Status Change Step 7: In the next section, indicate with check marks the reason for these requested changes.

Alabama Health Insurance And Optional Status Change Step 8: The next section concerns documentation of dependents and is only to be completed if seeking family coverage.

Alabama Health Insurance And Optional Status Change Step 9: The next section is only to be completed if you have the PEEHIP Supplemental Plan or other currently in effect group health, dental or vision coverage.

Alabama Health Insurance And Optional Status Change Step 10: The next section must be completed if you or your dependents are eligible for Medicare.

Alabama Health Insurance And Optional Status Change Step 11: The next section is only to be completed if you retired after September 30, 2005.

Alabama Health Insurance And Optional Status Change Step 12: Sign and date the bottom of the page. Mail the completed document to the address at the top of the first page.

Federal Poverty Level Discount (FPL) Application

INSTRUCTIONS: ALABAMA FEDERAL POVERTY LEVEL ASSISTANCE APPLICATION (FPL) (Form 2G)

Alabama public education employees who have a combined family income less than or equal to 200% of the Federal Poverty Level may apply for assistance. To do so, they must be enrolled in the state's Public Education Employees' Health Insurance Plan. Form 2G, used to request assistance, is located on the website of the Retirement Systems of Alabama. This document can also be used to request children's health insurance.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 1: The first section concerns subscriber information. Enter your Social Security number and name on the first line.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 2: On the second line, enter your mailing address, city, state and zip code.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 3: On the third line, enter your home and work phone numbers.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 4: On the fourth line, indicate whether you are married, single, divorced, legally separated or widowed with a check mark.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 5: The next section is only for those seeking children's health insurance. Indicate with a check mark whether any children are enrolled in Medicaid. If yes, give their names.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 6: A table is provided to list all household members. On line A of the first column, enter the name of the subscriber. On line B, enter the name of their spouse. On lines C through F, list all children under age 19 living in your household.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 7: In the second column, provide all listed household members' Social Security numbers.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 8: In the third column, provide all listed household members' dates of birth.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 9: In the fourth column, provide all listed household members' gender.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 10: In the fifth column, describe the relationship to you of all listed household members. Enter your requested effective date and answer all remaining questions as instructed.

Alabama Federal Poverty Level Assistance Application (FPL) 2G Step 11: Sign and date the form.

WC Assessment Form WCC10

INSTRUCTIONS: ALABAMA ASSESSMENT REPORT FOR INSURANCE COMPANIES, SELF-INSURERS AND GROUP FUNDS (WCC Form 10)

Alabama insurance companies, group funds and self-insured businesses must file a WCC Form 10 on an annual basis. This form can be obtained from the website of the Alabama Department of Labor.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 1: Enter your company name.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 2: Enter the name of a contact person.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 3: Enter your mailing and physical address.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 4: Enter your NCCI, FEIN, SI and GSI numbers.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 5: Enter your telephone number.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 6: Enter any subsidiaries if you are a self-insured company.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 7: Enter your total compensation paid.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 8: Enter your total medical costs paid.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 9: Enter your total attorney fees paid.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 10: Enter your total administrative expenses paid.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 11: Enter your total court settlements paid.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 12: Enter the total of all these expenses.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 13: Print your name where indicated.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 14: The bottom of the form must be completed in the presence of a notary public. Print your name again and enter your corporate title.

Alabama Assessment Report For Insurance Companies, Self-Insurers And Group Funds WCC Form 10 Step 15: Sign the form and give your title.

Revoke Election Form IB09

INSTRUCTIONS: ALABAMA REVOKE ELECTION FORM STATE EMPLOYEES' HEALTH INSURANCE COVERAGE (Form IB09)

To cancel dependent coverage included in Alabama state employees' health insurance coverage, a form IB09 should be used. This document can be obtained from the website of the Alabama State Employees' Insurance Board.

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 1: Print your name on the first blank line.

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 2: Enter your contract number on the second blank line.

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 3: Enter your work telephone number on the third blank line.

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 4: Enter your agency name on the fourth blank line.

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 5: Check the line next to the first statement if you have added dependents through marriage, birth or adoption of a child. Check the line next to the second statement if you have lost dependents.

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 6: The next five statements concern various changes in the employment status of you or your spouse. Check the line next to any applicable statements.

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 7: Check the next line if the dependant has lost coverage due to their age.

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 8: Check the next line if you are documenting a change of residence or worksite.

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 9: Check the next line if you are complying with a family relations judgment, decree or order.

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 10: Check the next line if revoking coverage due to a Medicare or Medicaid entitlement.

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 11: Check the next line if taking leave under the Family and Medical Leave act.

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 12: Check any of the next three lines if applicable.

Alabama Revoke Election Form State Employees' Health Insurance Coverage IB09 Step 13: On the next blank line, enter the date on which the qualifying event occurred. Sign and date the bottom of the page.

Annual Insurance Return 2013

INSTRUCTIONS: NEVADA ANNUAL INSURANCE PREMIUM TAX RETURN (Form IPT-R)

Nevada premium tax payments are submitted on an annual basis using the form discussed in this article. This document can be obtained from the website of the Nevada Department of Taxation.

Nevada Annual Insurance Premium Tax Return IPT-R Step 1: In the top right-hand corner, enter your tax identification number, federal ID, premium tax, retaliatory tax and total remittance.

Nevada Annual Insurance Premium Tax Return IPT-R Step 2: On line 1, enter your total premiums and consideration.

Nevada Annual Insurance Premium Tax Return IPT-R Step 3: On line 2, multiply line 1 by 3.5% and enter the resulting product. If a qualified risk retention group, multiply line 1 by 2% and enter the resulting product.

Nevada Annual Insurance Premium Tax Return IPT-R Step 4: On line 3a, if you qualify, calculate your home office credit as instructed.

Nevada Annual Insurance Premium Tax Return IPT-R Step 5: If qualified, enter the amount of ad valorem taxes paid on line 3b.

Nevada Annual Insurance Premium Tax Return IPT-R Step 6: Enter the maximum credit allowed on line 3c.

Nevada Annual Insurance Premium Tax Return IPT-R Step 7: Enter your allowable home office credits on line 3d.

Nevada Annual Insurance Premium Tax Return IPT-R Step 8: Subtract line 3d from line 2. Enter the resulting difference on line 4.

Nevada Annual Insurance Premium Tax Return IPT-R Step 9: Enter your life/health guaranty association offset on line 5.

Nevada Annual Insurance Premium Tax Return IPT-R Step 10: On line 6, enter your property/casualty guaranty association offset.

Nevada Annual Insurance Premium Tax Return IPT-R Step 11: On line 6A, enter the total overpayments applied from previous years.

Nevada Annual Insurance Premium Tax Return IPT-R Step 12: On line 6B, enter the total overpayments refunded by Nevada for the year specified.

Nevada Annual Insurance Premium Tax Return IPT-R Step 13: On line 7, enter your net premium tax due.

Nevada Annual Insurance Premium Tax Return IPT-R Step 14: If filing late, calculate your penalty and daily interest due on lines 8 and 9 as instructed.

Nevada Annual Insurance Premium Tax Return IPT-R Step 15: Add lines 7 through 9. Enter the resulting sum on line 10.

Nevada Annual Insurance Premium Tax Return IPT-R Step 16: Sign and print your name. Enter the date, your email address and telephone number.

Insurance

Annual Tobacco User Premium Discount Application IB06

Non-Tobacco User Discount Application IB05