FREE 9+ Sample Universal Claim Forms in PDF | MS Word

The healthcare system is complex as it is, even more for submissions of health insurance claims. That is why Universal Claim Forms were created to simplify the process of submitting health insurance claims and medical claims. The Health Insurance Portability and Accountability Act (HIPAA) includes a series of administrative provisions that require the Department of Health and Human Services to use national standards for simplifying healthcare transactions. These standards ensure consistency which ultimately makes it easier for healthcare providers to submit claims. You may also look at our other Medical Claim Forms for various samples and information about other types.

Universal Credit Claim Form

Universal Dental Claim Form

Universal Prescription Claim Form

Universal Claim Review Form

Universal Claim Time Limit Appeal Form

Users of Universal Claim Forms

Physicians, hospitals, clinics, and other medical care providers use Universal Claim Forms to submit medical claims for their patients. After these claims have been submitted, the health insurance company would then process that claim and compute all medical expenses that are covered under the patient’s insurance policy. The health insurance provider would then expend funds based on the computed value. Then they would forward any remaining balance that is not covered, to the medical care provider, so that the patient can settle this remaining balance directly with their medical service provider.

Types of Universal Claim Forms

The use of a Universal Claim Form with standardized formats allows the seamless and easier process of submitting medical expense claims. There are various types depending on what kind of medical claim is being submitted. For example, a Universal Dental Claim Form is used to submit claims for dental expenses, and a Universal Prescription Claim Form is used to submit claims for prescription medication, such as compounded medication, a personalized type of medication wherein medications are made by mixing individual ingredients together based on the dosage and strength prescribed by the physician or healthcare practitioner. You may also see our Health Care Claim Forms for more samples that are easy to download.

Universal Claim Form in PDF

Universal Claim Form for Insurance

Prescription Reimbursement Claim Form

Universal Claim Form in Word

Universal Claim Form Example

General Parts of a Universal Claim Form

• Patient or Insured Information 

This contains the personal information of the patient or insured member, such as his name, address, date of birth, sex, contact details, and other necessary personal information. This is used for demographic purposes as well, and usually the patient and the insured member’s information are different, in that the person insured is not the patient, so they are provided in different areas of the form. This is also the section where the patient’s insurance policy number and insurance plan for the coverage of medical expenses will be indicated. The patient’s employment details or school details are also included here.

• Physician or Supplier Information

This is the part where the information of the attending physician and the medical care facility will be provided. The name of the physician, and the name and address of the medical care facility should be included, along with any contact details. Aside from this, it should also be stated when the patient was admitted or serviced, what symptoms were present, what the diagnosis is, and what medical treatments have been administered to the patient.

Along with the submission of a Universal Claim Form, there should also be supporting documents to substantiate the medical claim, such as a Patient Information Form and Patient Health Record, among others. You may also see our Disability Claim Forms for making claims for benefits in the event of an accident that leads to a temporary or permanent disability.