<h4><strong>Claims Support Forms</strong></h4>
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<td colspan="2" rowspan="1" width="587" style="padding: 0.75pt; width: 440pt; height: 15pt;"><p style="margin: 12pt 0in 12pt 0.1in;"><span style="color: rgb(58, 58, 58);">{fontweight=500:Claims Forms}<br>These forms are for providers to use to submit their TOP Claims to the TOP Claims Processor.</span></p></td>
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<td colspan="1" rowspan="1" style="padding: 0.75pt; height: 15pt;"><p style="margin: 12pt 0.1in 12pt 0in;"><span style="color: rgb(58, 58, 58);">Claim Development Worksheet</span></p></td>
<td colspan="1" rowspan="1" style="padding: 0.75pt; height: 15pt;"><p style="margin: 12pt 0.1in;"><span style="color: rgb(58, 58, 58);">{ downloaddocs=/providers/tco-media/documents/CDW-FINAL-MAY2024-ARABIC:Arabic} | {downloaddocs=/providers/tco-media/documents/CDW-FINAL-ENGLISH-MAY-2024:English} | {downloaddocs=/providers/tco-media/documents/CDW-FINAL-MAY2024-FRENCH:French } | {downloaddocs=/providers/tco-media/documents/CDW-FINAL-MAY2024-GERMAN:German } | {downloaddocs=/providers/tco-media/documents/CDW-FINAL-MAY2024-Greek:Greek } | {downloaddocs=/providers/tco-media/documents/CDW-FINAL-MAY2024-Italian:Italian } | {downloaddocs=/providers/tco-media/documents/CDW-FINAL-JAPANESE-MAY-2024:Japanese} | {downloaddocs=/providers/tco-media/documents/CDW-FINAL-MAY2024-Korean:Korean } | {downloaddocs=/providers/tco-media/documents/CDW-FINAL-MAY2024-Polish:Polish } | {downloaddocs=/providers/tco-media/documents/CDW-FINAL-MAY2024-Portuguese:Portuguese } | {downloaddocs=/providers/tco-media/documents/CDW-FINAL-MAY2024-SPANISH:Spanish } | {downloaddocs=/providers/tco-media/documents/CDW-FINAL-MAY2024-TURKISH:Turkish }</span></p></td>
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<td colspan="1" rowspan="1" style="padding: 0.75pt; height: 15pt;"><p style="margin: 12pt 0.1in 12pt 0in;"><span style="color: rgb(58, 58, 58);">CMS 1500 Claim Form</span></p></td>
<td colspan="1" rowspan="1" style="padding: 0.75pt; height: 15pt;"><p style="margin: 12pt 0.1in;"><span style="color: rgb(58, 58, 58);">{downloaddocs=/providers/tco-media/documents/CMS1500_ver02-12:English}</span></p></td>
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<td colspan="1" rowspan="1" style="padding: 0.75pt; height: 15pt;"><p style="margin: 12pt 0.1in 12pt 0in;"><span style="color: rgb(58, 58, 58);">UB-04 Claim Form</span></p></td>
<td colspan="1" rowspan="1" style="padding: 0.75pt; height: 15pt;"><p style="margin: 12pt 0.1in;"><span style="color: rgb(58, 58, 58);">{downloaddocs=/providers/tco-media/documents/UB-04Form:English}</span></p></td>
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<td colspan="2" rowspan="1" width="587" style="padding: 0.75pt; width: 440pt; height: 15pt;"><p style="margin: 12pt 0in 12pt 0.1in;"><span style="color: rgb(58, 58, 58);">{fontweight=500:Signature on File Forms}<br>These forms are for providers to capture beneficiary signature/consent to submit claims on their behalf and release medical records to International SOS.</span></p></td>
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<td colspan="1" rowspan="1" style="padding: 0.75pt; height: 15pt;"><p style="margin: 12pt 0.1in 12pt 0in;"><span style="color: rgb(58, 58, 58);">Beneficiary Signature on File</span></p></td>
<td colspan="1" rowspan="1" style="padding: 0.75pt; height: 15pt;"><p style="margin: 12pt 0.1in;"><span style="color: rgb(58, 58, 58);">{downloaddocs=/providers/tco-media/documents/beneficiary-sof-final-may-2018:English} |{downloaddocs=/providers/tco-media/documents/beneficiary-sof-final-may-2018-japanese:Japanese}</span></p></td>
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<td colspan="1" rowspan="1" style="padding: 0.75pt; height: 15pt;"><p style="margin: 12pt 0.1in 12pt 0in;"><span style="color: rgb(58, 58, 58);">Patient Administrative Form (PAF)</span></p></td>
<td colspan="1" rowspan="1" style="padding: 0.75pt; height: 15pt;"><p style="margin: 12pt 0.1in;"><span style="color: rgb(58, 58, 58);">{downloaddocs=/providers/tco-media/documents/patient-administration-form-english-paf-may-2023:English} | {downloaddocs=/providers/tco-media/documents/patient-administration-form-french-paf-sept-2020:French} | {downloaddocs=/providers/tco-media/documents/patient-administration-form-german-paf-may-2023:German} | {downloaddocs=/providers/tco-media/documents/patient-administration-form-italian-paf-sept-2020:Italian} | {downloaddocs=/providers/tco-media/documents/patient-administration-form-japanese-paf-jan-2020:Japanese} | {downloaddocs=/providers/tco-media/documents/patient-administration-form-korean-paf-jan-2020:Korean} | {downloaddocs=/providers/tco-media/documents/patient-administration-form-polish-paf-sept-2020:Polish} | {downloaddocs=/providers/tco-media/documents/patient-administration-form-portuguese-paf-sept-2020:Portuguese} | {downloaddocs=/providers/tco-media/documents/Patient-Administration-Form-TURKISH-2024:Turkish}</span></p></td>
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<td colspan="1" rowspan="1" style="padding: 0.75pt; height: 15pt;"><p style="margin: 12pt 0.1in 12pt 0in;"><span style="color: rgb(58, 58, 58);">Provider Signature on File</span></p></td>
<td colspan="1" rowspan="1" style="padding: 0.75pt; height: 15pt;"><p style="margin: 12pt 0.1in;"><span style="color: rgb(58, 58, 58);">{downloaddocs=/providers/tco-media/documents/Provider-SOF-JAN2025-ENGLISH:English} | {downloaddocs=/providers/tco-media/documents/Provider-SOF-JAN2025-ARABIC:Arabic} | {downloaddocs=/providers/tco-media/documents/Provider-SOF-JAN2025-FRENCH:French} | {downloaddocs=/providers/tco-media/documents/Provider-SOF-JAN2025-GERMAN:German} | {downloaddocs=/providers/tco-media/documents/Provider-SOF-JAN2025-ITALIAN:Italian} | {downloaddocs=/providers/tco-media/documents/Provider-SOF-JAN2025-JAPANESE:Japanese} | {downloaddocs=/providers/tco-media/documents/Provider-SOF-JAN2025-KOREAN:Korean} | {downloaddocs=/providers/tco-media/documents/Provider-SOF-JAN2025-POLISH:Polish} | {downloaddocs=/providers/tco-media/documents/Provider-SOF-JAN2025-PORTUGUESE:Portuguese} | {downloaddocs=/providers/tco-media/documents/Provider-SOF-JAN2025-SPANISH:Spanish} | {downloaddocs=/providers/tco-media/documents/Provider-SOF-JAN2025-TURKISH:Turkish}<br></span></p></td>
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<td colspan="1" rowspan="1" style="padding: 0.75pt; height: 15pt;"><p style="margin: 12pt 0.1in 12pt 0in;"><span style="color: rgb(58, 58, 58);">Beneficiary Consent to Release of Medical Information Form (ROMIF)</span></p></td>
<td colspan="1" rowspan="1" style="padding: 0.75pt; height: 15pt;"><p style="margin: 12pt 0.1in;"><span style="color: rgb(58, 58, 58);">{downloaddocs=/providers/tco-media/documents/ROMIF-English-Aug-2021:English}</span></p></td>
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<td colspan="2" rowspan="1" width="587" style="padding: 0.75pt; width: 440pt; height: 15pt;"><p style="margin: 12pt 0in 12pt 0.1in;"><span style="color: rgb(58, 58, 58);">{fontweight=500:Electronic Payment Forms}<br>These forms are for providers to get paid electronically for TOP Claims.</span></p></td>
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<td colspan="1" rowspan="1" style="padding: 0.75pt; height: 15pt;"><p style="margin: 12pt 0.1in 12pt 0in;"><span style="color: rgb(58, 58, 58);">Electronic Fund Transfer (EFT) Form</span></p></td>
<td colspan="1" rowspan="1" style="padding: 0.75pt; height: 15pt;"><p style="margin: 12pt 0.1in;"><span style="color: rgb(58, 58, 58);">{downloaddocs=/providers/tco-media/documents/EFT-Form-English-FEB2022:English} | {downloaddocs=/providers/tco-media/documents/EFT-Form-French-FEB2022:French} | {downloaddocs=/providers/tco-media/documents/EFT-Form-German-FEB2022:German} | {downloaddocs=/providers/tco-media/documents/EFT-Form-Greek-FEB2022:Greek} | {downloaddocs=/providers/tco-media/documents/EFT-Form-Providers-FINAL-Feb-2022-HUNGARIAN:Hungarian} | {downloaddocs=/providers/tco-media/documents/EFT-Form-Italian-FEB2022:Italian} | {downloaddocs=/providers/tco-media/documents/EFT-Form-Portuguese-FEB2022:Portuguese} | {downloaddocs=/providers/tco-media/documents/EFT-Form-Spanish-FEB2022:Spanish} | {downloaddocs=/providers/tco-media/documents/EFT-Form-Turkish-FEB2022:Turkish}</span></p></td>
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<td colspan="1" rowspan="1" style="padding: 0.75pt; height: 15pt;"><p style="margin: 12pt 0.1in 12pt 0in;"><span style="color: rgb(58, 58, 58);">Electronic Fund Transfer (EFT) for Providers using a Billing Agency</span></p></td>
<td colspan="1" rowspan="1" style="padding: 0.75pt; height: 15pt;"><p style="margin: 12pt 0.1in;"><span style="color: rgb(58, 58, 58);">{downloaddocs=/providers/tco-media/documents/EFT-Form-BA-English-FEB2022:English} | {downloaddocs=/providers/tco-media/documents/EFT-Form-BA-French-FEB2022:French} | {downloaddocs=/providers/tco-media/documents/EFT-Form-BA-German-FEB2022:German} | {downloaddocs=/providers/tco-media/documents/EFT-Form-BA-Greek-FEB2022:Greek} | {downloaddocs=/providers/tco-media/documents/EFT-Form-Providers-with-Billing-Agency-HUNGARIAN:Hungarian} | {downloaddocs=/providers/tco-media/documents/EFT-Form-BA-Italian-FEB2022:Italian} | {downloaddocs=/providers/tco-media/documents/EFT-Form-BA-Portuguese-FEB2022:Portuguese} | {downloaddocs=/providers/tco-media/documents/EFT-Form-BA-Spanish-FEB2022:Spanish} | {downloaddocs=/providers/tco-media/documents/EFT-Form-BA-Turkish-FEB2022:Turkish}</span></p></td>
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<td colspan="1" rowspan="1" style="padding: 0.75pt; height: 15pt;"><p style="margin: 12pt 0.1in 12pt 0in;"><span style="color: rgb(58, 58, 58);">Automated Clearing House (ACH) and Wire Payment Form</span></p></td>
<td colspan="1" rowspan="1" style="padding: 0.75pt; height: 15pt;"><p style="margin: 12pt 0.1in;"><span style="color: rgb(58, 58, 58);">{downloaddocs=/providers/tco-media/documents/ACH-WPF-FEB2022:English}</span></p></td>
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<td colspan="1" rowspan="1" style="padding: 0.75pt; height: 15pt;"><p style="margin: 12pt 0.1in 12pt 0in;"><span style="color: rgb(58, 58, 58);">W9 Form – This form should be sent together with the ACH and Wire Payment Form</span></p></td>
<td colspan="1" rowspan="1" style="padding: 0.75pt; height: 15pt;"><p style="margin: 12pt 0.1in;"><span style="color: rgb(58, 58, 58);">{downloaddocs=/providers/tco-media/documents/W9-Form-FEB2022:English}</span></p></td>
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<td colspan="2" rowspan="1" width="587" style="padding: 0.75pt; width: 440pt; height: 15pt;"><p style="margin: 12pt 0in 12pt 0.1in;"><span style="color: rgb(58, 58, 58);">{fontweight=500:Secure Claims Portal Forms}<br>These forms are for providers to benefit from all the key functions of the Secure Claims Portal, including registering for online claims submission and receiving your remittance advice via email</span></p></td>
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<td colspan="1" rowspan="1" style="padding: 0.75pt; height: 15pt;"><p style="margin: 12pt 0.1in 12pt 0in;"><span style="color: rgb(58, 58, 58);">Electronic Data Interchange (EDI) Agreement Form: Online Claims Submission Registration</span></p></td>
<td colspan="1" rowspan="1" style="padding: 0.75pt; height: 15pt;"><p style="margin: 12pt 0.1in;"><span style="color: rgb(58, 58, 58);">{downloaddocs=/providers/tco-media/documents/EDI-Agreement-Form-ENG-OCT2021:English} | {downloaddocs=/providers/tco-media/documents/EDI-Enrollment-Form-ARABIC:Arabic} | {downloaddocs=/providers/tco-media/documents/EDI-Agreement-Form-FRE-OCT2021:French} | {downloaddocs=/providers/tco-media/documents/edi-enrollment-form--final-january-2020-german:German} | {downloaddocs=/providers/tco-media/documents/EDI-Agreement-Form-GRE-OCT2021:Greek} | {downloaddocs=/providers/tco-media/documents/EDI-Enrollment-Form-HUNGARIAN:Hungarian} | {downloaddocs=/providers/tco-media/documents/EDI-Agreement-Form-ITA-OCT2021:Italian} | {downloaddocs=/providers/tco-media/documents/EDI-Agreement-Form-POL-OCT2021:Polish} | {downloaddocs=/providers/tco-media/documents/EDI-Agreement-Form-POR-OCT2021:Portuguese} | {downloaddocs=/providers/tco-media/documents/EDI-Enrollment-Form-ROMANIAN:Romanian} | {downloaddocs=/providers/tco-media/documents/EDI-Agreement-Form-SPA-OCT2021:Spanish} | {downloaddocs=/providers/tco-media/documents/EDI-Agreement-Form-TUR-OCT2021:Turkish}<br></span></p></td>
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<td colspan="1" rowspan="1" style="padding: 0.75pt; height: 15pt;"><p style="margin: 12pt 0.1in 12pt 0in;"><span style="color: rgb(58, 58, 58);">Electronic Remittance Advice (ERA) Authorization & Instructions Form: Remittance Advice Email</span></p></td>
<td colspan="1" rowspan="1" style="padding: 0.75pt; height: 15pt;"><p style="margin: 12pt 0.1in;"><span style="color: rgb(58, 58, 58);">{downloaddocs=/providers/tco-media/documents/ERA-Form-OCT2021:English} | {downloaddocs=/providers/tco-media/documents/ERA-Form-Oct2021-German:German} | {downloaddocs=/providers/tco-media/documents/ERA-Form-Oct2021-Spanish:Spanish} | {downloaddocs=/providers/tco-media/documents/ERA-Form-Oct2021-Italian:Italian} | {downloaddocs=/providers/tco-media/documents/ERA-Form-Oct2021-French:French} | {downloaddocs=/providers/tco-media/documents/ERA-Form-Oct2021-Portuguese:Portuguese} | {downloaddocs=/providers/tco-media/documents/ERA-Form-Oct2021-Greek:Greek} | {downloaddocs=/providers/tco-media/documents/ERA-Form-Oct2021-Turkish:Turkish} | {downloaddocs=/providers/tco-media/documents/ERA-Form-Oct2021-Polish:Polish}</span></p></td>
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</table>
<p><br></p>
<h4> </h4>