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Online Claim Form
 
This claim form is to be used only if your provider did not file claims directly to ICS on your behalf. International Claims Services must receive claims within one hundred eighty days (180) after first day of treatment. Please ensure that you provide copies of invoices, receipts, and any other information available for review.
 
Policy holder (Primary Insured) Information
 
Name: Employer:
Policy Number:
Current Resident Address and Country:
Telephone: Fax:
E-mail:
 
Section A
 
Please check who this claim is for:
Primary Insured
Gender: Male Female Date of Birth:
Maritial Status: Married Single
Dependent Insured
Name: Date of Birth:
Gender: Male Female Relation: Spouse Child
Current Country of Residence:
If dependent is a child 21 years and older, is child a full-time student? Yes No
If yes please provide:
Name of School: Location:
 
All full time students must have a letter verifying full-time student status from their school’s registrar office at the beginning of each school year.
 
Section B
 
Describe problem, symptom or complaint. How did it occur?:
Date Illness or Injury occurred:
Dr’s Diagnosis and/or results of your visit:
Is this claim for Maternity treatment? Yes No Delivery Date:
Has diagnosis and/or treatment for same condition or related condition been given previously? If so, state dates, results, kind of treatment, prescribed drugs and name of doctor or facility:
Was illness or injury due in any way to:
 
The patients occupation? Yes No
An automobile Accident? Yes No
Any type of accident? Yes No
 
If yes, provide details, including date of accident
 
Is this patient also covered by:
 
Any other group health plan? Yes No
Medicare or other Govt. Agency? Yes No
No-Fault auto carrier? Yes No
 
If yes, provide name and address of other source
 
 
Doctor / Facility Information
 
Doctor/Facility/Provider Name: Phone Number:
Address / Country: Provider e-mail:
 
Payment Information
 
Please make payment to: Member Provider (Payment by check)
Payment Type: Please make payment as marked below:
 
Send check and EOB to:
Member Address on Part 1
Other Mailing Address
Send by Electronic Direct Deposit (Bank must be located in US), or Wire Transfer (Banks located outside of US.)
 
Treatments and / or Prescribed Drugs
 
The following treatments and or prescribed drugs were provided to me and the charges for each are listed below (ATTACH RECEIPTS in order to receive payment). To add more charges, click on image.
Date of Service Description of Each Service
and/or Prescribed Drug 		Cost Currency Add / Delete Rows
Add new row after this
Total Amount Paid by Patient  
Total unpaid balance still due to provider  
 
Attachments
 
Please attach scanned copies of receipts / documents here. To add more files, click on image. You can upload up to 10 files with total files size of 20 MB.
 
Add / Delete Files Upload File
Add More Attachments
 
  The above answers are true and correct to the best of my knowledge. I authorize any physician, medical institution, pharmacy, insurance company, employer, labor union, or association to release information to GBG/Tiecare International inc. as is required to properly pay all benefits, if any, due me, my spouse, or parent of this claim. A photocopy of this authorization shall be considered effective and valid as the original.
 
 
 
 
 
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