P.O. Box 660044
Dallas, Texas 75266-0044
Each item on this form needs to be completed.
Instructions for completion are listed on the reverse side.
Please Print or Type
1 Insured/Subscriber Name (Last, First, Middle Initial)
Insured/Subscriber Identification Number (from ID card)
Patient's Full Name (Last, First, Middle)
City & State
Patient's Date of Birth
■ Male ■ Female
Date of Retirement
_____ /_______ /____
Patient's Relationship to Insured
1. ■ Self 2. ■ Spouse 3. ■ Child 4.■ Other (explain)
3 Type of treatment received:
Check only one type and attach itemized statements.
Please use a separate claim form for each different type
*Please note: Preventive care includes immunizations,
routine well baby care, routine physical examinations,
vision and he