COMMERCIAL MEMBER CLAIM
This form may be used for Health Net and Health Net Life Insurance Company products or products offered by your employer group.
Complete the claim form as indicated below. For your protection, California law requires the following to appear on this form: Any person
who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement
STEP 1. in state prison. Fill out a separate form for each member submitting bills for covered services. To avoid any delay be sure to answer
each question completely. ASK YOUR PHYSICIAN TO COMPLETE THE BACK OF THIS FORM.
HEALTH NET COMMERCIAL CLAIMS
P.O. BOX 14702
LEXINGTON, KY 40512
PLEASE ATTACH FULLY ITEMIZED BILLS AND / OR PROOF OF PAYMENT.
SUBSCRIBER INFORMATION - Employee Social Security # must be indicated to assure prompt processing of this request.
SUBSCRIBER SOCIAL SECURITY #
DATE OF BIRTH (M