claim form


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claim form

(klām fōrm)
Document that gives necessary information about patient, treating provider, and coded treatment, including charges; filed for payment of benefits by carrier of dental insurance.
[L. forma, shape, contour]
References in periodicals archive ?
Mr Justice Collins considered that it was reasonable of the council to expect a paper copy of the claim form, however, he concluded that the council had not been prejudiced by the non-service of the claim form and on this basis he ordered that permission for judicial review be granted, and that the council must pay the costs of the hearing in the sum of PS9,500 plus VAT.
All persons or entities (including, without limitation, individuals, partnerships, corporations, joint ventures, estates, trusts, and governmental units) that believe they possess a potential or claimed right to payment, or a claim of any nature, against any of the Receivership Entities and believe that they are owed any money by, or are entitled to a distribution from, any of the Receivership Entities must submit a Proof of Claim Form, unless otherwise expressly stated herein, regardless of whether such claim has been acknowledged by the Receiver (each a "Claimant").
Sherb agreed to create a fund of $400,000 to be divided among all Settlement Class Members who send in valid claim forms (after deduction of Court-approved expenses).
Class Members should be aware that the agreement offered by Spectrum requires them to turn over to Spectrum their right to participate in a pro rata residual distribution, which could involve for many Class Members substantial additional cash payments over and above the amounts in the Class Member's VM1 Claim Forms.
If you are a member of the Individual Defendant Settlement Class, in order to be potentially eligible to share in the distribution of the Individual Defendant Net Settlement Fund, you are required to file a Proof of Claim Form at this time.
merchants and consumers over the next decade, became final on May 31, 2005, and claim forms have been mailed to members of the Class.
If you are a potential member of the Settlement Class, in order to be potentially eligible to share in the distribution of the settlement fund, you are required to file a Proof of Claim Form at this time.
The settlement will provide Class Members (as defined below) who timely submit a valid Claim Form (as defined in the Stipulation) with the option of receiving a cash payment or free Red Bull products.
To make a claim, you must complete and send in a Claim Form certifying that you received on or after September 17, 2008, either (a) a pre-recorded call advertising Vivint goods or services; (b) more than one telephone call in a 12-month period promoting Vivint goods or services to a number registered on the National Do Not Call Registry or Vivint's internal Do Not Call list; or (c) a telephone call made to a cellular telephone using an automatic telephone dialing system.
However, businesses that receive a pre-printed claim form in the mail only have until October 29 to challenge that estimate in writing.
1 ] If you held Eligible Shares you may qualify for a cash payment by sending in a claim form.
Eligible individuals can also get the claim form from the FTB's Website at www.