INSTRUCTIONS: SOUTHLAND NATIONAL INDEMNITY AND CANCER CLAIM FORM
Alabama current and retired public employees who have received medical care for cancer and other conditions should file a claim for medical insurance compensation with Southland Benefit Solutions, the designated provider for state government workers. The document discussed in this article can be found on the website of the Retirement Systems of Alabama.
Southland National Indemnity And Cancer Claim Form Step 1: The top half of the form is the employee's statement. Enter your name and subscription contract number in boxes 1 and 2.
Southland National Indemnity And Cancer Claim Form Step 2: Enter your home address in box 3.
Southland National Indemnity And Cancer Claim Form Step 3: Enter your name in box 5, date of birth in box 6 and age in box 7.
Southland National Indemnity And Cancer Claim Form Step 4: Indicate your gender in box 8 with a check mark.
Southland National Indemnity And Cancer Claim Form Step 5: In box 8, indicate with a check mark whether the patient is the subscriber, their spouse or their child.
Southland National Indemnity And Cancer Claim Form Step 6: Give the subscriber's telephone number in box 9.
Southland National Indemnity And Cancer Claim Form Step 7: In box 10, give a description of your injury or illness or the doctor's diagnosis.
Southland National Indemnity And Cancer Claim Form Step 8: Enter the physician's name and address, the name of your hospital if confined, the dates of your admission and discharge, the date your accident occurred or sickness began and the date you first received treatment.
Southland National Indemnity And Cancer Claim Form Step 9: Indicate with a check mark whether your condition was related to accident or illness.
Southland National Indemnity And Cancer Claim Form Step 10: Sign and date the top half of the form.
Southland National Indemnity And Cancer Claim Form Step 11: The bottom half of the form is the attending physician's statement which documents the services you received and provides identifying information about the doctor. This should be completed by your doctor and then returned to you.
Southland National Indemnity And Cancer Claim Form Step 12: Mail the completed form along with an itemized copy of your hospital bill to the address listed on the second page.