I understand that payment and satisfaction of this claim will be from Federal and State funds, and that any false claims, statements, or documents, or concealment of a material fact, may be …

PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary to process this claim. I also request payment of government …

The information we obtain to complete claims under these programs is used to identify you and to determine your eligibility. It is also used to decide if the services and supplies you received are …

If you write on the form, use black or blue ink and print clearly and legibly. You can also use your computer to complete this form and then print it out to mail it to us.

Attention California Residents: For your protection California law requires notice of the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the …

Please refer to OMB Control No. 2900-0075 in any correspondence. Do not send your completed VA Form 21-4138 to this email address. VA FORM 21-4138, JUL 2024 Page 2

You only need to fill out this form if your health care professional isn't filing the claim for you. Even if not part of the Cigna network (out-of-network), your health care professional still can file the …

I authorize the insurer to verify details and process my claim.

As a result of this joint effort, the 1500 Claim Form is accepted nationwide by most insurance entities as the standard claim form/attending physician statement for submission of medical …