Claim Forms

How to File a Claim
Click the link for more information about how to file a claim form for Dental, Vision & Hearing.

Please follow the steps below to file a claim.

To file a claim:

  1. Click on the appropriate claim form below and print it out.
  2. Fill out the form as instructed.
  3. Mail or fax the form to the address or fax number shown above.

Cancer and Disability Claim Form
Use this form if you have a cancer policy or a disability policy with Medico Insurance Company or Medico Life Insurance Company.

Hospital Confinement Claim Form
Use a standard claim form from your provider's office if you have a hospital indemnity plan with Medico Insurance Company or Medico Life Insurance Company.

Life Insurance Claim Form
Use this form if you have a life insurance policy with Medico Life Insurance Company.

Final Expense-Funeral Home Claim Form
Use this form if you have a Final Expense-Funeral Home policy with Medico Life Insurance Company.

Dental Claim Form
Use this form if you have a dental policy with Medico Insurance Company. Staff from the dentist's office can complete and submit this form with the billing.

Vision Claim Form
Use this form if you have a vision policy with Medico Insurance Company. Staff from the provider's office can complete and submit this form with the billing.

Hearing Claim Form
Use this form if you have a hearing policy with Medico Insurance Company. Staff from the doctor's office can complete and submit this form with the billing.

 

Short-Term Care Forms


Short-Term Care Claim Form
Use this form if you have a short-term care insurance policy form NHA06, NHA07, or NHA30 issued through Medico Insurance Company or Medico Life Insurance Company and you are making a claim for nursing facility care, assisted living care or home health care. This form is for policies purchased in 2006 or later.

Short-Term Care Attending Physician's Statement
This form is used for short-term care policy forms NHA06, NHA07, or NHA30 purchased in 2006 or later. It is a form that must be completed and submitted by the attending physician.

Short-Term Care Facility Certification of Care
This is a form for those NHA06, NHA07, or NHA30 policyholders who are moving from one facility to another or who are going into a facility for the first time. Staff from the facility need to complete and submit this form.

Short-Term Care Monthly Verification of Continuing Care
This is a form to be completed by facility staff. This form is used to verify continuing care for NHA06, NHA07, or NHA30 policyholders. It must be submitted each month with the billing.

Claimant's Supplemental Report
This is a form to be completed by facility staff. This form is used to verify continuing care for NHA06, NHA07, or NHA30 policyholders. It must be submitted each month with the billing.

 

Wyoming External Review Request

 Complete the forms below to begin the external review process.

Wyoming External Review Process Overview 

Checklist 

External Review Request Form 

Request for Fee Waiver 

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