Adventist - Tangiers International

Primary Participant Name*
Claimant (Patient) Name*
Participant
- Male
- Female
Patient
- Male
- Female
Date of Birth*
Patients Date of Birth*
Home Telephone*
Work Telephone
Fax Number
Email Address*
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Current Address (if different from home address)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Policy Number*
Citizenship of Claimant*
Home Country of Claimant (Country where you principally reside)*
Country Visited (Tangiers may request a copy of your passport)*
Is the Claimant: A full-time Student?*
- Yes
- No
Please provide the name and address of school*
Is the Claimant: Employed?*
- Yes
- No
Please provide the name and address of employer*
Do you or any family members have other coverage (medical, indemnity or liability) which might help cover hospital and medical expenses?*
- Yes
- No
Name fo company
Address
Policyholder
Policy number
Is this group insurance?*
- Yes
- No

Please complete for new claims
How did the condition begin? State fully all symptoms and describe the condition in detail from the beginning
When did the first symptoms of this condition begin? State the exact date, if possible: (If this claim is a result of an accident, please contact our office to obtain the ACCIDENT QUESTIONNAIRE)
Have you ever had or been treated for the same kind of illness or injury?
- Yes
- No
When? (Name, address and telephone number of attending physician)
Name, address and telephone number of family physician (even if not consulted)
What ailments, diseases, illnesses, conditions or injuries have you had during the last five years? Please provide name and/or description of each condition, dates involved, and the name, address and telephone numbers of attending physicians

*
- I verify that all information contained in this form is true, correct and complete to the best of my knowledge. I authorize any licensed doctor, practitioner of the healing arts, hospital, clinic, health related facility, pharmacy, government agency, insurance company, group policyholder, employee or benefit plan administrator having information as to the care, advice, treatment, diagnosis or prognosis of any physical or mental condition, or the financial or employment status of the person named below, to provide this information to Tangiers International. I understand that I have the right to receive a copy of this authorization upon request. A copy of this shall be as valid as the original. This authorization is valid for twelve months
*
- ASSIGNMENT OF BENEFITS AUTHORIZATION: I authorize payment of medical benefits to the doctor or other supplier of services submitting the attached bills.
**Please attach all original itemized bills for services and supplies**
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Adventist Frontier Missions Support Services