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Southland Benefit Solutions Vision Claim Form

Southland Benefit Solutions Vision Claim Form

 

INSTRUCTIONS: ALABAMA SOUTHLAND BENEFIT SOLUTIONS VISION CLAIM FORM

 

 

Alabama public employees enrolled in the state's vision care administered through Southland Benefit Solutions use the form discussed in this article to file a claim for vision care. This document can be obtained from the website maintained by Southland Benefit Solutions.

 

Alabama Southland Benefit Solutions Vision Claim Form Step 1: In box 1, indicate whether you are enrolled in Medicare, Medicaid, a group health plan or another plan with a check mark.

 

Alabama Southland Benefit Solutions Vision Claim Form Step 2: In box 1a, enter the insured's ID number.

 

Alabama Southland Benefit Solutions Vision Claim Form Step 3: In box 2, enter the patient's name.

 

Alabama Southland Benefit Solutions Vision Claim Form Step 4: In box 3, enter the patient's date of birth and indicate their gender with a check mark.

 

Alabama Southland Benefit Solutions Vision Claim Form Step 5: In box 4, enter the insured's name.

 

Alabama Southland Benefit Solutions Vision Claim Form Step 6: In box 5, enter the patient's address.

 

Alabama Southland Benefit Solutions Vision Claim Form Step 7: In box 6, indicate the patient's relationship to the insured with a check mark.

 

Alabama Southland Benefit Solutions Vision Claim Form Step 8: In box 7, enter the insured's address.

 

Alabama Southland Benefit Solutions Vision Claim Form Step 9: In box 8, indicate the patient's marital and employment status with a check mark.

 

Alabama Southland Benefit Solutions Vision Claim Form Step 10: In box 9, enter the name of any other insured party. 

 

Alabama Southland Benefit Solutions Vision Claim Form Step 11: In box 9a, enter the policy or group number of the other insured party. In box 9b, enter their date of birth and indicate their gender with a check mark. Enter their employer or school name in box 9c and their insurance plan name or program name in box 9d,

 

Alabama Southland Benefit Solutions Vision Claim Form Step 12: In box 10, enter the insured's policy group or FECA number. In box 10a, enter the insured's date of birth and indicate their gender with a check mark. Enter their employer or school name in box 10b, their insurance plan name or program name in box 10c and indicate whether there is another health benefit plan in box 10d with a check mark. Complete the rest of the form as instructed.

 

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Application and Notice of Application and Hearing for Order to Quash Ex Parte Writ of Possession (Cl

Application and Notice of Application and Hearing for Order to Quash Ex Parte Writ of Possession (Cl

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Claim Form

Claim Form

 

INSTRUCTIONS: ALABAMA CLAIM FOR PERSONAL INJURY (Form A)

 

 

When involved in an incident resulting in personal injury in Alabama involving some government agency or department, you can use a form A to seek compensation. This document can be obtained from the website of the Alabama Department of Finance.

 

Alabama Claim For Personal Injury A Step 1: If you are filing this as a supplement to a previously filed claim, enter its number and the department or agency processing it.

 

Alabama Claim For Personal Injury A Step 2: On line 1, give the name and mailing address of the claimant, as well as their home and business telephone numbers and their Social Security or federal identification number. If filing on behalf of an injury done to a minor, the guardian or parent completing this form should give the minor's name and age, as well as their own name and relationship to the minor.

 

Alabama Claim For Personal Injury A Step 3: On line 2, if the claimant is represented by an attorney completing this form who is authorized to discuss all related correspondence, give their name, mailing address and telephone number. 

 

Alabama Claim For Personal Injury A Step 4: On line 3, give the date of the accident or injury.

 

Alabama Claim For Personal Injury A Step 5: If this is not a claim related to an accident or injury, enter the date on which the claim began on line 4.

 

Alabama Claim For Personal Injury A Step 6: On line 5, give the county, city, building name and all location information about the site of the accident or injury.

 

Alabama Claim For Personal Injury A Step 7: On line 6, provide a description of the event in your own words. Note any prior fiscal year invoices and give their numbers. Note if you have incurred any travel expenses. Line 7 is for those seeking compensation for uninsured medical expenses, permanent disability or lost wages or leave used to detail the amount of the compensation sought.

 

Alabama Claim For Personal Injury A Step 8: Line 8 is for those seeking compensation for damage to personal property. Line 9 is for those seeking compensation for other, miscellaneous expenses. 

 

Alabama Claim For Personal Injury A Step 9: Enter the total amount claimed on line 10 and any payments received on line 11. Sign and date the form before a notary public.

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CL-438 Medical Expense Claim

CL-438 Medical Expense Claim

 

INSTRUCTIONS: BLUECROSS BLUESHIELD OF ALABAMA MEDICAL EXPENSE CLAIM (Form CL-438)

 

 

Alabama public employees enrolled in a state health care plan administered by BlueCross BlueShield of Alabama file the form discussed in this article when their physician or other provider does not file a claim. This document can be obtained from the website maintained by BlueCross BlueShield of Alabama.

 

BlueCross BlueShield Of Alabama Medical Expense Claim CL-438 Step 1: In box 1, enter the patient's last name, first name and middle initial.

 

BlueCross BlueShield Of Alabama Medical Expense Claim CL-438 Step 2: In box 2, enter your contract number as it appears on your ID card. Include any letters if applicable.

 

BlueCross BlueShield Of Alabama Medical Expense Claim CL-438 Step 3: In box 3, enter your group number as it appears on your ID card or your place of employment.

 

BlueCross BlueShield Of Alabama Medical Expense Claim CL-438 Step 4: In box 4, enter your date of birth.

 

BlueCross BlueShield Of Alabama Medical Expense Claim CL-438 Step 5: Indicate your sex with a check mark in box 5.

 

BlueCross BlueShield Of Alabama Medical Expense Claim CL-438 Step 6: In box 6, indicate the patient's relationship to the contract holder with a check mark.

 

BlueCross BlueShield Of Alabama Medical Expense Claim CL-438 Step 7: In box 7, enter the name, address and telephone number of the contract holder.

 

BlueCross BlueShield Of Alabama Medical Expense Claim CL-438 Step 8: In box 8, indicate whether the patient is covered under any other group health insurance plan with a check mark. If yes, enter the name of the policy holder, the name and address of the insuring company and the policy effective date. Indicate whether the patient is entitled to Medicare benefits under Part A or Part B with a check mark. If so, give their Medicare number.

 

BlueCross BlueShield Of Alabama Medical Expense Claim CL-438 Step 9: In box 9, indicate what the patient's condition was related to with a check mark. 

 

BlueCross BlueShield Of Alabama Medical Expense Claim CL-438 Step 10: In box 10, enter the diagnoses.

 

BlueCross BlueShield Of Alabama Medical Expense Claim CL-438 Step 11: In box 11, enter the phone number, name and address of the ordering physician.

 

BlueCross BlueShield Of Alabama Medical Expense Claim CL-438 Step 12: Sign and date the bottom of the page.

 

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Form J400 ADA Dental Claim Form

Form J400 ADA Dental Claim Form

 

INSTRUCTIONS: ALABAMA ADA DENTAL CLAIM FORM

 

 

Alabama public employees receiving supplemental dental coverage administered by Southland Benefit Solutions can use the claim form discussed in this article. This document can be obtained from the website maintained by Southland Benefit Solutions.

 

Alabama ADA Dental Claim Form Step 1: In box 1, indicate the kind of transaction being documented with a check mark.

 

Alabama ADA Dental Claim Form Step 2: In box 2, enter the predetermination or preauthorization number.

 

Alabama ADA Dental Claim Form Step 3: In box 3, enter your dental benefit plan or insurance company name, address, city, state and zip code.

 

Alabama ADA Dental Claim Form Step 4: In box 4, indicate whether you have other dental or medical coverage with a check mark. If no, you can skip steps 5 through 11.

 

Alabama ADA Dental Claim Form Step 5: In box 5, enter the name of the policyholder or subscriber of the other dental or medical coverage.

 

Alabama ADA Dental Claim Form Step 6: In box 6, enter the date of birth of this policyholder or subscriber.

 

Alabama ADA Dental Claim Form Step 7: In box 7, indicate this policyholder or subscriber's gender with a check mark.

 

Alabama ADA Dental Claim Form Step 8: In box 8, enter their policyholder or subscriber ID. This can be either their Social Security number or ID number.

 

Alabama ADA Dental Claim Form Step 9: In box 9, enter the plan or group number.

 

Alabama ADA Dental Claim Form Step 10: In box 10, indicate the relationship of the patient to the person named in box 5 with a check mark.

 

Alabama ADA Dental Claim Form Step 11: In box 11, enter the name, address, city, state and zip code of the other insurance company or dental benefit plan.

 

Alabama ADA Dental Claim Form Step 12: In box 12, enter the name, address, city, state and zip code of the policyholder or subscriber of the insurance company named in box 3.

 

Alabama ADA Dental Claim Form Step 13: In box 13, enter this policyholder or subscriber's date of birth.

 

Alabama ADA Dental Claim Form Step 14: Indicate this policyholder or subscriber's gender with a check mark in box 14.

 

Alabama ADA Dental Claim Form Step 15: Complete the rest of the form as instructed.

 

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Order for Release and Redelivery of Property (Claim and Delivery)

Order for Release and Redelivery of Property (Claim and Delivery)

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Supplemental Claim Form

Supplemental Claim Form

 

INSTRUCTIONS: ALABAMA SUPPLEMENTAL CLAIM (Form C)

 

 

To file a claim with the state of Alabama for supplemental expenses following an accident, you must do so within a year of the incident, or within two if the accident resulted in death. The form can be found on the website of the Alabama Board of Adjustment.

 

Alabama Supplemental Claim C Step 1: If this is a supplement to a previously filed claim, give the claim number and the department or agency with which it was filed.

 

Alabama Supplemental Claim C Step 2: In section 1, give the claimant's name, mailing address and Social Security or federal identification number. Also enter their home and business telephone numbers.

 

Alabama Supplemental Claim C Step 3: If the claimant is a minor child, section 1 should be completed by their parent and guardian. If so, on the blank line provided, enter the name and age of the minor and the name and relationship to the minor of the person completing this document.

 

Alabama Supplemental Claim C Step 4: Section 2 should only be completed if an attorney is representing the claimant and has completed this form. If so, give their name and mailing attorney. This will authorize the attorney to handle correspondence and official communications regarding this return.

 

Alabama Supplemental Claim C Step 5: In section 3A, indicate if this is a claim for uninsured medical expenses. If so, enter the dollar amount. Indicate with a check mark if you have insurance. If so, enter the name of the insuring company. In section 3B, indicate if this injury resulted in permanent disability. If so, enter the amount sought and give a description of the disability. Enter the rate of pay at the time of accident or injury.

 

Alabama Supplemental Claim C Step 6: In section 3C, indicate if you are seeking compensation for leave time from work used  for recovery. If so, give the dollar amount of the wages lost or compensation sought for time off work and the number of hours, days or weeks you were unable to work. Give the dates for which you seek compensation and your rate of pay at the time of the incident.

 

Alabama Supplemental Claim C Step 7: Document miscellaneous expenses you seek compensation for in section 3D and provide an explanation. Total all compensation sought on line 4. Sign the form before a notary public.

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Form WC 4 Claims Summary Form

Form WC 4 Claims Summary Form

 

INSTRUCTIONS: ALABAMA CLAIMS SUMMARY FORM (Form WC 4)
 
When an Alabama employee is injured on the job, their employer is required to provide workers compensation coverage for treatment. The insurance company is required to submit a form WC 3 or WC 4 showing money paid to the worker. The form is found on the website of the Alabama Department of Labor.
 
Alabama Claims Summary Form WC 4 Step 1: Indicate with a check mark if this form documents a suspension, settlement or an amended form.
 
Alabama Claims Summary Form WC 4 Step 2: On line 1, enter the employee's name. 
 
Alabama Claims Summary Form WC 4 Step 3: On line 2, enter the employee's Social Security number.
 
Alabama Claims Summary Form WC 4 Step 4: On line 3, enter the employer's name.
 
Alabama Claims Summary Form WC 4 Step 5: On line 4, enter the employer's unemployment compensation number.
 
Alabama Claims Summary Form WC 4 Step 6: On line 5, enter the date of the injury.
 
Alabama Claims Summary Form WC 4 Step 7: On line 6, enter the date the disability began in this period.
 
Alabama Claims Summary Form WC 4 Step 8: On line 7, enter the name of the insurance carrier.
 
Alabama Claims Summary Form WC 4 Step 9: On line 8, enter the claim number.
 
Alabama Claims Summary Form WC 4 Step 10: On line 9, enter the service company number.
 
Alabama Claims Summary Form WC 4 Step 11: On line 10, enter the name, address and telephone number of the insurance officer filing this form.
 
Alabama Claims Summary Form WC 4 Step 12: Fees paid are documented on lines 11 through 17. Do not include payments documented on a previously filed claims summary form. On line 11, enter the date the last compensation payment was made.
 
Alabama Claims Summary Form WC 4 Step 13: On line 12, indicate whether the claimant worked during this disability period. If so, give the dates of their work.
 
Alabama Claims Summary Form WC 4 Step 14: On line 13, enter the average weekly wage (AWW) and compensation rate.
 
Alabama Claims Summary Form WC 4 Step 15: Complete lines 14 through 17 as directed to document all other payments and fees disbursed.
 
Alabama Claims Summary Form WC 4 Step 16: Sign and date the form and give your title.
 

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Assignment to Youthful Trainee Status

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Declaration for Ex Parte Writ of Possession (Claim and Delivery)

Declaration for Ex Parte Writ of Possession (Claim and Delivery)

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