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Forms

Bank Draft
The option is available to have your Long Term Care policy premiums deducted directly from your checking or savings
account. Please follow the instructions on the form if you would like your policy premiums deducted automatically.

Authorization to release medical information
Due to HIPAA regulations we are unable to release your personal information without your authorization. If you would
like to grant access to your policy information to someone else, please print, complete and mail the attached form to our
office.

Claim Form
To submit a request for an eligibility determination, a claim form and additional information is required to initiate this
process. Please read the "To File a Claim" instructions with the claim form.

Home Health Progress Notes
This form is provided for your convenience in the event your home health care provider does not have their own daily
progress notes or billing forms.

HIPAA Claims Processing
HIPAA Claims Processing
It may be necessary for us to request additional information to reach an eligibility determination. By completing and
submitting this form to us you give us authorization to obtain personal information, including health information, from
your physicians, medical practitioners, hospitals, clinics, etc. If this form is not submitted with your claim form it may delay
our handling of your claim.

Direction to Pay
If you choose to assign your long term care insurance benefits to a covered provider you must submit the Direction to
Pay form to SHIP. The Direction to Pay form is provided as a convenience to our policyholders and their care providers
to assign benefits to the care provider, but not the rights under the policy.

W-9 Request for Taxpayer Identification Number and Certification
If you choose to assign your long term care insurance benefits to your covered provider, this form is required from your
covered provider.

Affidavit and Indemnity Agreement
This form is required to recognize and work with deponents as the sole, legal, equitable, and unrestricted heirs to the
deceased's estate.

Facility Cognitive Questionnaire
Additional information may be required for eligibility determinations. The form must be completed by the nursing staff of
your long term care facility.

Claim Information Package
The claim information package contains the documents to explain the claim filing process and the forms you may need
when filing a new claim.

How to file a claim
This document outlines the forms that are necessary to file a new claim under your SHIP long term care policy and
explains the timeframes associated with filing a new claim.

Nursing Facility Checklist
This form is designed to help you stay organized while submitting a new nursing facility claim. This checklist does not
need to be returned.

Home Healthcare Checklist
This form is designed to help you stay organized while submitting a new home health care claim. This checklist does not
need to be returned.