Claims Support Forms

<h4>Claims Support Forms</h4>   <table border="0" style="width: 440pt;" width="587"> <tbody> <tr style="height: 15.0pt;"> <td colspan="2" rowspan="1" width="587" style="width: 440.0pt; padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">{fontweight=500:Claims Forms} These forms are for providers to use to submit their TOP Claims to the TOP Claims Processor.</td> </tr> <tr style="height: 15.0pt;"> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">Claim Development Worksheet</td> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">{ downloaddocs=/providers/tco-media/documents/CDW-FINAL-MAY2024-ARABIC:Arabic} |  {downloaddocs=/providers/tco-media/documents/CDW-MAR2025-ENG: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 }</td> </tr> <tr style="height: 15.0pt;"> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">CMS 1500 Claim Form</td> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">{downloaddocs=/providers/tco-media/documents/CMS1500_ver02-12:English}</td> </tr> <tr style="height: 15.0pt;"> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">UB-04 Claim Form</td> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">{downloaddocs=/providers/tco-media/documents/UB-04Form:English}</td> </tr> <tr style="height: 15.0pt;"> <td colspan="2" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">{fontweight=500:Medical Care Pre-Approval Forms} Providers can use these pre-approval forms when applicable for specific conditions or medical care that require pre-approval.</td> </tr> <tr style="height: 15.0pt;"> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">Obesity Management with Weight-Loss Medications Pre-Approval Form</td> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">{downloaddocs=/providers/tco-media/documents/Pre-Approval-Weight-Loss-Medication-Form-Dec2025:English} | {downloaddocs=/providers/tco-media/documents/TOP-Pre-approval-weightloss-medications-GER:German} | {downloaddocs=/providers/tco-media/documents/TOP-Pre-approval-weightloss-medications-ITA:Italian} | {downloaddocs=/providers/tco-media/documents/TOP-Pre-approval-weightloss-medications-JAP:Japanese} | {downloaddocs=/providers/tco-media/documents/TOP-Pre-approval-weightloss-medications-KOR:Korean} | {downloaddocs=/providers/tco-media/documents/TOP-Pre-approval-weightloss-medications-SPA:Spanish}</td> </tr> <tr style="height: 15.0pt;"> <td colspan="2" rowspan="1" width="587" style="width: 440.0pt; padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">{fontweight=500:Signature on File Forms} These forms are for providers to capture beneficiary signature/consent to submit claims on their behalf and release medical records to International SOS.</td> </tr> <tr style="height: 15.0pt;"> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">Beneficiary Signature on File</td> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">{downloaddocs=/providers/tco-media/documents/beneficiary-sof-final-may-2018:English} |{downloaddocs=/providers/tco-media/documents/beneficiary-sof-final-may-2018-japanese:Japanese}</td> </tr> <tr style="height: 15.0pt;"> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">Patient Administrative Form (PAF)</td> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">{downloaddocs=/providers/tco-media/documents/PAF-FEB2025-ENG:English} | {downloaddocs=/providers/tco-media/documents/PAF-FEB2025-FRE:French} | {downloaddocs=/providers/tco-media/documents/PAF-FEB2025-GER:German} | {downloaddocs=/providers/tco-media/documents/PAF-FEB2025-ITA: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/PAF-FEB2025-POL:Polish} | {downloaddocs=/providers/tco-media/documents/PAF-FEB2025-POR:Portuguese} | {downloaddocs=/providers/tco-media/documents/PAF-FEB2025-SPA:Spanish} | {downloaddocs=/providers/tco-media/documents/PAF-FEB2025-TUR:Turkish}</td> </tr> <tr style="height: 15.0pt;"> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">Provider Signature on File</td> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">{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}</td> </tr> <tr style="height: 15.0pt;"> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">Beneficiary Consent to Release of Medical Information Form (ROMIF)</td> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">{downloaddocs=/providers/tco-media/documents/ROMIF-English-Aug-2021:English}</td> </tr> <tr style="height: 15.0pt;"> <td colspan="2" rowspan="1" width="587" style="width: 440.0pt; padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">{fontweight=500:Electronic Payment Forms} These forms are for providers to get paid electronically for TOP Claims.</td> </tr> <tr style="height: 15.0pt;"> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">Electronic Fund Transfer (EFT) Form</td> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">{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}</td> </tr> <tr style="height: 15.0pt;"> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">Electronic Fund Transfer (EFT) for Providers using a Billing Agency</td> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">{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}</td> </tr> <tr style="height: 15.0pt;"> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">Automated Clearing House (ACH) and Wire Payment Form</td> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">{downloaddocs=/providers/tco-media/documents/ACH-WPF-FEB2022:English}</td> </tr> <tr style="height: 15.0pt;"> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">W9 Form – This form should be sent together with the ACH and Wire Payment Form</td> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">{downloaddocs=/providers/tco-media/documents/W9-Form-FEB2022:English}</td> </tr> <tr style="height: 15.0pt;"> <td colspan="2" rowspan="1" width="587" style="width: 440.0pt; padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">{fontweight=500:Secure Claims Portal Forms} 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</td> </tr> <tr style="height: 15.0pt;"> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">Electronic Data Interchange (EDI) Agreement Form: Online Claims Submission Registration</td> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">{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} </td> </tr> <tr style="height: 15.0pt;"> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">Electronic Remittance Advice (ERA) Authorization & Instructions Form: Remittance Advice Email</td> <td colspan="1" rowspan="1" style="padding: .75pt .75pt .75pt .75pt; height: 15.0pt;">{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}</td> </tr> </tbody> </table>

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