Claim Forms, based on the name, are forms used to claim reimbursement or benefits from an organization or company. There are certain eligibility requirements that vary in every organization. Once you qualify, you are to pass supporting documents or receipts to substantiate your claim and fill out certain Claim Forms. The company or organization will then review the details of your claim so that they can decide on whether to approve or deny it. If a claim application is denied, some companies allow their claimants to file an appeal.

Users of Claim Forms include insurance companies, business organizations, educational institutions, and government agencies that provide financial assistance during certain circumstances, such as the SSA or the Social Security Administration. You may see our samples of Social Security Administration Forms for more information and reference on these types of Claim Forms.

Expense Claim Form Examples

Health Care Expense Claim Form

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Size: 42 KB

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Medical Expense Claim Form

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Size: 96 KB

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Employee Expense Claim Form

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Size: 2 MB

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Pharmacy Claim Forms

Compounded  Medication Claim Form

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Size: 104 KB

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Pharmacy Benefit Services Claim Form

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Size: 62 KB

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Drug Claim Forms

Commercial Drug Claim Form

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  • PDF

Size: 311 KB

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Prescription Drug Claim Form

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  • PDF

Size: 688 KB

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Drug Claim Form in PDF

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Size: 655 KB

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Medical Claim Form Examples

Blue Cross Medical Claim Form

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Size: 91 KB

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Industrial Dental Care Expenses Claim Form

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Size: 290 KB

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Major Medical Claim Form

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Size: 577 KB

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Expense Claim Forms

These types of Claim Forms are used by business organizations for expenses incurred by their employees. These expenses would have to have a business purpose for the employee to be reimbursed if he used his own savings. A few examples of business expenses include expenses for materials and business trips. These expenses are necessary for the operation and development of a business.

Health insurance companies also use Expense Claim Forms for claims for medical expenses, such as laboratory tests and medication. You may also see our Reimbursement Request Forms for the requisition of reimbursement for other types of expenses.

Types of Expense Claim Forms

  • Health Care Expense Claim Form – This is used when a person has a health plan and wants to file a claim for the reimbursement of expenses for health care services.
  • Employee Expense Reimbursement Form – This is used by business organizations for employees to file a claim for business expenses they incurred.

Things to Keep in Mind

When filling out an Expense Claim Form, a breakdown of the expenses are to be included, along with the details of each line item. The description, quantity, purpose, and other relevant information about the expense should be indicated so that the company can check if these expenses are feasible and practical. After a breakdown is provided, the total amount for reimbursement is then stated.

Substantiation is very vital in processing reimbursements. It is not that a company does not trust the claimants, but there are too many cases of fraud nowadays that it is hard to just take someone’s word for something. Supporting documents are always necessary when you apply for something, especially if what you’re applying for is a claim.

Original copies of detailed receipts are to be presented along with the forms. If the copy is not original, a brief explanation should be included as to why the original copy could not be presented. Many companies do not accept credit card statements or checks to be used for substantiation.

Every Expense Claim Form has to be filled out with accurate and complete information to avoid confusion and misunderstanding. The information on every form is already segregated into subsections to allow easier input of information. It is then the claimant’s responsibility to ensure that all information on the form is accurate and complete. This is very crucial because the company will have to review these details and use them as a basis for the approval (or denial) of the claim.

Aside from Expense Claim Forms, Expense Report Forms are also used by business organizations no matter what field they are in. Financial stability is a key for the continuation of every business, and one way to achieve that is to make sure that the company has net profit each year. The net profit is calculated by subtracting the total expenses of the company for the year to its total income. In calculating the total expenses, Expense Report Forms come in handy.

Health Care Claim Forms

Extended Health Care Claim Form

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Size: 334 KB

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Health Insurance Claim Form

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Size: 492 KB

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Health Care Expense Claim Form

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Size: 825 KB

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General Insurance Claim Form

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Size: 95 KB

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Disability Claim Forms

Disability Claim Application Form

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Size: 97 KB

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Employee’s Disability Benefits Application Form

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Size: 146 KB

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Sample Disability Claim Form

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Size: 129 KB

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Long Term Disability Claim Form

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Size: 37 KB

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Travel Claim Forms

Travel Insurance Claim Form

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Size: 59 KB

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Travel Reimbursement Claim Form

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Size: 1 MB

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Smart Traveller Claim Form

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Size: 128 KB

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Claim Withdrawal Forms

Request for Claim Withdrawal Application Form

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Size: 54 KB

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Commercial Claim Withdrawal Form

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Size: 553 KB

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Small Claim Withdrawal Form

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Size: 3 KB

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Pharmacy Claim Forms

Health insurance providers have certain health plans that provide coverage for the cost of prescription medication. They have a list of pharmacies that are considered as participants in this health plan, which means that the health insurance provider has partnered with the pharmacy to provide covered services to their members.

This is all well and good, but there are times when the medication prescribed to the member is not available in any of the participating pharmacies. For this circumstance, the member would still be reimbursed for the cost of the medication, but a Pharmacy Claim Form would have to be filled out by the member.

Depending on the health insurance provider, a check is then sent in the mail within 4 to 6 weeks from the time the claim is submitted, given that it was approved. There are also Universal Claim Forms, such as Universal Prescription Claim Forms, used to streamline such claims, and other Health Care Claim Forms used for other health care services and expenses.

Along with the Pharmacy Claim Form, a copy of the prescription receipts from the pharmacy should also be submitted. The prescription receipts should show the following information:

  • The name of the patient or member
  • The prescription number
  • The date the prescription was filled
  • The drug name, strength, and its national drug code
  • The quantity bought and days supply (how many days the supply of medication will last)
  • The cost of each drug
  • The total amount paid by the patient or member

Information to be Included on Pharmacy Claim Forms

  • Member Information: This contains the personal and policy information of the insured member. This includes the member’s name, address, contact number, and policy number. This part should be filled out by the member and affixed with his signature.
  • Patient Information: This part is usually filled out if the member is not the patient. The patient could be the member’s spouse or dependent. In this section, the patient has to affix his signature and his relationship with the member has to be indicated as well.
  • Pharmacy Information: This section is filled out by the pharmacist and affixed with his signature. This includes the pharmacy’s name, address, telephone number, and National Provider Identifier (NPI) or National Boards of Pharmacy (NABP) number.
  • Prescription Information:  This basically includes information that can be found on the prescription receipt, such as the name and strength of the medication, and its national drug code, among other things.

Money Claim Forms

Unclaimed Money Claim Form

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Size: 274 KB

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Property Money Claim Form

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Size: 80 KB

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Prize Money Claim Form

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Size: 107 KB

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Quit Claim Forms

Free Quit Claim Deed Form

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Size: 610 KB

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Generic Quit Claim Deed Form

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Size: 113 KB

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Sample Quit Claim Deed Form

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Size: 6 KB

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Proof of Claim Forms

Proof of Claim Withdrawal Form

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Size: 184 KB

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Administrative Proof of Claim Form

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Size: 148 KB

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Sample Proof of Claim Form

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Size: 551 KB

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Proof of Claim Release Form

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Size: 392 KB

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Custom Claim

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Size: 73 KB

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52. Expense Claim Form

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Size: 701 KB

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Medical Claim Forms

Medical Claim Forms are used for filing claims for medical expenses. This kind of Claim Form is used by health insurance companies and medical care providers. Medical claims can either be submitted by the insured member or by the medical care provider. What happens is that the hospital or clinic will forward the claim to the health insurance company, and then it will be reviewed.

An Explanation of Benefits is then provided by the health insurance company after a standard processing period. The Explanation of Benefits will contain information on how much of the medical expenses are covered by your insurance policy, and how much are not covered and would have to be settled directly with your medical care provider. You may also see our Dental Claim Form samples for filing claims for dental expenses.

Things to Remember

  • When filing a medical claim, it is important to file it within 90 days from the day you received the service. Fo inpatient services, the 90 days starts from the day you checked out of the facility. This number may vary depending on your health insurance provider. It is also advised to submit or file a claim as close to the service date as possible.
  • Be sure to input all information on the form accurately and clearly. Aside from the receipt of your payment to substantiate the claim, it is also advisable to include diagnosis codes and service codes for a faster and more seamless approval of your claim. You can get these information from your medical care provider.
  • Once you have filled out the necessary forms, you should also make a copy of the forms, receipts, and service details to be kept for future reference.

The information to be included Medical Claim Forms are very much similar with that of a Pharmacy Claim Form, but instead of the pharmacy information, it would ask for the medical care provider’s information. In addition to that, it would also include information about the accident, if the medical condition or physical injury is the result of an accident. For accidents, you may also utilize our Accident Report Forms to report vehicular or road accidents.

Disability Claim Forms

Whether a person is temporarily or permanently disabled, and whether the disability is long-term or short-term, there are Disability Claim Forms available for the filing of claims for disability benefits. Disability benefits can be claimed from an employer, especially if the disability is the result of an accident that occurred in the workplace, from an insurance provider that provides disability benefits, or from a corresponding government agency, such as the Social Security Administration. Financial assistance is to be provided to the claimant for his daily expenses. A Disability Claim Form helps the receiving organization in screening the claims they receive to avoid fraud.

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