Please submit your claim promptly. Claim forms must be sent within 90 days of the date you first received medical care. To ensure that your claim is processed in a timely manner, please follow the instructions that are provided on the back of the form.

Send your completed Claim Form and required documentation to:

We understand that information we receive is personal and should be protected against unauthorized access. We do not release coverage, claims or medical information to anyone except as required or permitted by law. If you, as the parent of a minor child, should desire to appoint a representative to act on your behalf in communications with us for the academic year, simply click here. Please print, sign and mail or fax the designation of a personal representative information to us at the address or fax indicated above.

If you want us to release specific information for a specific purpose for a limited time only, you must authorize us to do so. Please click here, print, sign and mail or fax the "Authorization for an Individual" to us (as above).

What is HIPAA?

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