Claim Reimbursement Form

Use this form if you want to submit a claim to Select Health, rather than your provider submitting the claim for you. Select Health will only reimburse claims for covered services, procedures, and diagnoses. To find out if a service is covered, please call Member Services at 800–538–5038.

Select a plan

Claim Type

Member & Patient Information

Member ID Number

Member's First Name

Member's Last Name

Date of Birth

Patient's Name

Patient's Date of Birth

Relationship to Member

Address

Phone

Email Address

OTHER INSURANCE INFORMATION

Does the patient have other insurance besides Select Health?

Yes

Insurance Company

Is this the member's primary insurance?

Other Insurance Company Policy ID #

Policyholder's Name

Date of Birth

Policyholder's Relationship to Member

Claim INformation

Provider or Facility

Provider or Facility Tax ID

National Provider ID (NPI)

Provider Phone Number

Physical Address

Does this provider have a different mailing address?

Mailing Address

Date of Service

Billed Amount

Description of Services

Diagnostic Codes

Code Enter the medical diagnostic code.

Add Field

Procedure Codes

Add Field

Tooth Number & Surface Letter

Tooth Number & Surface Letter Enter all tooth number & surface letters billed for the service.

Add Field

Upload Receipt

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Digital Signature