International Claims Transmittal
Return this form with the original medical bill or claim form via mail or fax to:
Check here if this is a
PO Box 740817
Atlanta, GA 30374
Please complete all sections of this transmittal form. Claims may be delayed if all sections of this form are not completed. However, this
does not guarantee that additional information will not be requested from you to process the claim. You will be advised in writing should
additional information be required.
Please complete a new & separate claim transmittal form for:
* Each patient * Each inpatient hospital stay
* Each different healthcare provider
* Each currency type
Section 1 – Member & Patient Information
___ I am an Expatriate or retiree living abroad.
___ I am traveling internationally for pleasure.
____ I am traveling internationally for business, however, live in the U.S.
Group Policy #
Member id #