Forms

You will need to submit forms to allow us to perform a variety of tasks for your Medico insurance policy. Here you’ll find forms to process claims, update information, provide authorizations, and more. If a form you need is not listed below, contact Customer Care at (800) 228-6080.

    Claim Forms

    • Medicare Supplement Claims

      Your healthcare providers will usually submit electronically to Medicare the billed charges for any Medical and Hospital expenses you incur. Medicare then processes benefits for expenses eligible under Part A and/or Part B of Medicare, and passes your claim electronically to us for consideration of benefits under your Medicare supplement policy. We will accept Medicare’s electronic submission of your claim to us as your notice of claim.

      For consideration of expenses that are not submitted electronically to us, a paper copy of your Medicare Summary Notice or Medicare Benefit Notice can serve as your notice of claim. This Medicare statement shows your Medicare Eligible Expenses and the amount approved and paid by Medicare. You may submit a paper copy of your Medicare statement to us or your healthcare provider may submit it to us on your behalf. If your claim is submitted electronically the requirements for claim forms and proof of loss will be met. 

    • Medico Insurance Company Forms

      Accident Policy

      • Accident Expense Claim Form: Use this form regarding your accidental injury expenses, such as emergency room, urgent care, follow-up care, surgery, x-rays, or therapy. 
      • Accidental Death & Dismemberment Claim Form: Use this form regarding your accidental dismemberment, such as loss of hands, arms, feet, or legs; paralysis; hearing; vision; or severe burn.
      • Claim Form — Proof of Death: Use this form regarding the death of a covered person. Please contact Customer Care before submitting claims.


      Cancer and Disability Policy


      Critical Illness Policy


      Dental, Vision, or Hearing Policies


      Final Expense — Funeral Home Policy


      Hospital Indemnity/Limited Benefit Policy


      Life Insurance Policy


      Recovery Care or Short-Term Facility Care Policy

      • Claim Form
      • 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.
      • 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.
      • 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.
    • Medico Corp Life Insurance Company Forms

      Hospital Indemnity/Limited Benefit Policy

      • Accident Medical Claim Form: Use this claim form for accidental injury. Injuries may include burn, dislocation, fracture, or laceration. Services may include emergency room visit, chiropractic, dental, physical therapy or x-ray as a result of the accidental injury.
      • Claim Form: Use this claim form all other claims under your hospital indemnity/limited benefit policy. 
      • Wellness and Diagnostic Test Claim Form: Use this claim form for wellness activities and screenings (i.e., annual physical, immunizations, cholesterol test, colonoscopy, PSA or PAP smear, or mammogram). Use this form also for alternative care treatments, such as yoga, therapeutic massage, or acupuncture.
      • Claim Form — Proof of Death: Use this form regarding the death of a covered person. Please contact Customer Care before submitting claims.


      Cancer Policy

      • Claim Form: Use this form regarding a cancer claim.
      • Travel Log Claim Form: Use this form to record your mileage and beginning/end destinations.
      • Wellness and Diagnostic Test Claim Form: Use this claim form for wellness activities and screenings (i.e., annual physical, immunizations, cholesterol test, colonoscopy, PSA or PAP smear, or mammogram). Use this form also for alternative care treatments, such as yoga, therapeutic massage, or acupuncture.


      Heart Attack/Stroke Policy

      • Claim Form: Use this form regarding a heart attack or stroke claim.
    • Life and Funeral Home Forms