International Member Reimbursement Claim Form

Instructions:
1. You will need your Health Care Professional/Provider to assist and supply information in completing sections III & IV of this form. It is recommended that you
bring this form with you to your appointment.
2. To request reimbursement, please submit the following to the address listed at the bottom of this form (any missing information may result in delay or denial of
the request):
a. This completed and signed reimbursement form
b. Proof of payment (receipt) for services being requested for reimbursement.
3. Most completed reimbursement requests are processed within 30 days. Incomplete requests may take longer.
4. Retain a copy of all receipts and documentation for your records.
5. If this form is not signed and dated by patient/guardian, reimbursement will not be made.
Section I: Subscriber Information
Subscriber Name Subscriber ID #

Section II: Member Information

Member Name (First, Last and M.I.) Member Date of Birth Member ID #
_____/_____/_______
Street Address City, State, Zip Telephone Number

Relationship to Subscriber Gender M F

Self Spouse Guardian Dependent Other

Section III: Provider Information (see Provider for assistance in completing this section)
Provider Name Country

Provider Address Individual, Group or Facility

City, State, Zip In what Currency was the bill paid?

Provider Phone Number In what Language was the bill written?

Section IV: Claim Information (see Provider for assistance in completing this section)
Date of Service
_____/_____/_______
Date of Service
_____/_____/_______
Date of Service
_____/_____/_______
Diagnosis: What were you seen for? Type of Service: Paid Amount
o Outpatient o Inpatient hospital care
o Emergency room visit o Other_________________ $
Diagnosis: What were you seen for? Type of Service: Paid Amount
o Outpatient o Inpatient hospital care
o Emergency room visit o Other_________________ $
Diagnosis: What were you seen for? Type of Service: Paid Amount
o Outpatient o Inpatient hospital care
o Emergency room visit o Other_________________ $
Total Amount Paid

Section V: Proof of Payment

Provide proof of service(s) with the following:
o An itemized bill from the provider of service, listing dates of service, services provided, and dollar amounts paid

Proof of payment through one of the following: (check which method applies)
o Receipt of payment by provider for cash payments. Cash payments MUST also include proof for source of funds (i.e., wire transfer, travelers check receipt,
credit card statement, bank statement).
o Financial Statement to include a copy of front and back of canceled check made out to the provider.
o Credit card statement including service receipt.

Section VI: Attestation and Signature

I attest that the above information is true and accurate and that the services were received and paid for in the amount requested as indicated above. I
acknowledge that if any information on this form is misleading or fraudulent, my coverage may be cancelled and I may be subject to criminal and/or civil
penalties for false health care claims. I understand that when the reimbursement payment is made it will contain information about the service (e.g., Provider
name, date, description of service). I also understand that Beacon may request any additional information it deems necessary to verify that services were
received and/or payment was made.
Print Name Member/Guardian Signature Date

Please mail this form and any supporting documents (e.g., proof of payment, receipt, etc.) to:
Beacon Health Strategies
GIC Member Reimbursements
PO Box 527
Woburn, MA 01801
Please note: Member claims can also be submitted electronically at http://mybeacon.beaconhs.com/. For more information about your benefits or submitting claims
electronically, please contact Beacons Member Services at 855-750-8980.
 International Member Reimbursement Claim Form Definitions
Subscriber Information Subscriber is the person:
Who enrolls in GIC and signs the membership application
form on behalf of him/herself & any dependents
In whose name the premium is paid
Subscriber ID is:
The same as Primary Insureds Member ID and can be found
on the front of the insurance card.
Member Name First and Last names and Middle Initial of Patient who received
services.
Member Date of Birth Date of Birth: Month (2 digits), Day (2 digits), and Year (4 digits) (e.g.,
MM/DD/YYYY)
Member ID # Group Number + suffix found on the front of members insurance
card.
Provider Information Information for the Provider who rendered the services.
Date(s) of Service The date(s) the services were provided to the member.
Diagnosis: What was the member seen for? Detailed description of illness or reason for treatment.
Proof of Services A document from the provider listing date(s) of service(s) provided
and dollar amounts paid.
Proof of Payment Documentation that validates and proves your payment.
Total Paid Amount Total amount for which you are requesting reimbursement.
If services were rendered outside of the U.S. If applicable, indicate in what country services were provided, in what
language the bill was written and in what currency the bill was paid.