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Cancer Claims

Please download, complete, and submit all necessary Documents

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1. Download the Claim Form

Claim Form Download
    Max file size: 20MB
Submit

2. HIPAA Authorization

HIPAA Auth Form Download
    Max file size: 20MB
Submit

3. Attending Physician Statement

Attending Physician Statement
    Max file size: 20MB
Submit

4. Pathology Report

    Max file size: 20MB
Submit

​5. Admission and Discharge Summary (In-patient Only)

    Max file size: 20MB
Submit

6. Outpatient Billings for Chemotherapy or Radiation 

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    Max file size: 20MB
Submit
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  • Forms
  • Our Products
    • Hospital Income
    • Heart
    • Cancer
    • Accident
    • Intensive Care
  • Agent Services
    • Employee Email Log-In
    • Career Opportunities
    • Agent Training Material
  • Portal Access Link
  • Wealth Care Admin