About SHIP Rehabilitation Claims Info Forms Common Questions Contact Us Helpful Info Forms Affidavit and Indemnity Agreement This form is required to recognize and work with deponents as the sole, legal, equitable, and unrestricted heirs to the deceased's estate. Authorization to Release Medical Information Due to HIPAA regulations, we are unable to release your personal information without your authorization. If you would like to grant access to your policy information to someone else, please print, complete, and mail the attached form to our office. Bank Draft The option is available to have your long-term care policy premiums deducted directly from your checking or savings account. Please follow the instructions on the form if you would like your policy premiums deducted automatically. Claim Form To submit a request for an eligibility determination, a claim form and additional information is required to initiate this process. Please read the "To File a Claim" instructions included in the Claim Information Package. Claim Information Package The claim information package contains the documents to explain the claim filing process and the forms you may need when filing a new claim. Claimant Care Needs Assessment Form This form is required to verify the needs of the claimant. It is to be completed by a licensed health care practitioner. Continued Monthly Residence (CMR) Form The CMR form must be completed for facility claims by an authorized representative of the facility on a monthly basis and submitted with the bill(s) after the end of each month. Direction to Pay If you choose to assign your long-term care insurance benefits to a covered provider, you must submit the Direction to Pay form to SHIP. The Direction to Pay form is provided as a convenience to our policyholders and their care providers to assign benefits to the care provider, but not the rights under the policy. HIPAA Claims Processing It may be necessary for us to request additional information to reach an eligibility determination. By completing and submitting this form to us you give us authorization to obtain personal information, including health information, from your physicians, medical practitioners, hospitals, clinics, etc. If this form is not submitted with your claim form it may delay our handling of your claim. Home Health Progress Notes This form is provided for your convenience in the event your home health care provider does not have their own daily progress notes or billing forms. Home Healthcare Checklist This form is designed to help you stay organized while submitting a new home health care claim. This checklist does not need to be returned. How to File a Claim This document outlines the forms that are necessary to file a new claim under your SHIP long-term care policy and explains the time frames associated with filing a new claim. Nursing Facility Checklist This form is designed to help you stay organized while submitting a new nursing facility claim. This checklist does not need to be returned. W-9 Request for Taxpayer Identification Number and Certification If you choose to assign your long-term care insurance benefits to your covered provider, this form is required from your covered provider. PA DEPT OF INSURANCE LEGAL PRIVACY POLICY SITE MAP ©2021