To download a claim form, select the state and policy type from
the dropdown boxes below. Complete the form and mail it to the
address provided in the form.
Independent Caregiver Forms
For use with all private-hire independent caregivers.
The Independent Caregiver Packet
includes Proof of Payment Requirements, Release of Liability,
Caregiver Biographical and Qualifications information, and itemized
Billing Statement and Daily Visit Notes. Click here
To download the stand-alone Itemized Billing
Statement and Daily Visit Notes form click
Questions? Click here to
review claims FAQ's.
Please note: These forms are PDF files. In order to view or
download any PDF files, you will need Acrobat Reader software. If
you do not have Acrobat Reader and wish to download it for free, click here to visit the Adobe Acrobat Reader