Medical/Dental Claim Form

You may choose to complete your Medical/Dental Claim Form by either printing our form below or scrolling down to the online eForm.

INSTRUCTIONS:

• YOU MUST COMPLETE EVERY APPLICABLE BOX ON THE FORM. A separate form must be submitted for each family member's expenses every time you submit a claim for payment. 
• When presenting a claim for payment, simply attach your itemized bills from providers of service. Each bill MUST contain the following information:

                   Name, Address, and Tax ID# of physician or provider of service
                   Name of patient
                   Date(s) of service rendered
                   Charge(s) made per service
                   Nature of illness or injury including diagnosis code(s) from the ICD-CM
                   Type of service(s) using the appropriate CPT code(s)

• Please check all bills for accuracy. Do not present cancelled checks or cash register receipts since they do not contain the required information and will delay processing.
• KEEP A COPY OF THIS FORM AND ANY BILLS YOU ATTACH.
• If choosing to print and mail the claim form, please send to: 

                   LifeWell Health Plans/CoreSource
                   P.O. Box 2920
                   Clinton, IA 52733

PRINTABLE CLAIM FORM   -or- use our online eForm below.                                                         

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