Common use of Required Medical Documentation Clause in Contracts

Required Medical Documentation. This section of the Medical Expense Certificate must be fully completed in order for your claim to be considered. Any corrections or additional information necessary to cure an incomplete Medical Expense Certificate must be submitted to NCSBT within two months of the expiration of the one-year deadline to file a claim. Provide all information required below regarding all medical expenses for which you are seeking reimbursement/payment (i.e., expenses not covered under the insurance, plans, or benefits programs identified above). You must provide updated, itemized medical provider statements which reflect date(s) of service, services rendered, International Classification of Diseases diagnostic codes (ICD-10 diagnostic codes), charges for services, payments, and any outstanding balances. You must also provide all applicable Explanation of Benefit statements. If additional space is needed, please list on a separate page and attach. “See attached” is not an acceptable response to this section: • Provider Name: Date(s) of Service: Medical Services Rendered: Original Amount of Bill: $ Total Amount Claimed for Payment to Provider of Outstanding Balance: $ Total Amount Claimed for Reimbursement of Out-of-Pocket Expense: $ • Provider Name: Date(s) of Service: Medical Services Rendered: Original Amount of Bill: $ Total Amount Claimed for Payment to Provider of Outstanding Balance: $ Total Amount Claimed for Reimbursement of Out-of-Pocket Expense: $ • Provider Name: Date(s) of Service: Medical Services Rendered: Original Amount of Bill: $ Total Amount Claimed for Payment to Provider of Outstanding Balance: $ Total Amount Claimed for Reimbursement of Out-of-Pocket Expense: $ • Provider Name: Date(s) of Service: Medical Services Rendered: Original Amount of Bill: $ Total Amount Claimed for Payment to Provider of Outstanding Balance: $ Total Amount Claimed for Reimbursement of Out-of-Pocket Expense: $ • Provider Name: Date(s) of Service: Medical Services Rendered: Original Amount of Bill: $ Total Amount Claimed for Payment to Provider of Outstanding Balance: $ Total Amount Claimed for Reimbursement of Out-of-Pocket Expense: $ I, , hereby certify that the information provided on this Medical Expense Certificate and the attached documentation represent all true, correct, current, and up-to-date information supporting this claim, and I have completed this form and provided such documentation to the best of my ability. This the day of , 20 . This form must be signed by the injured party or, if the injured party is a minor, by the injured party’s parent or guardian. Forms that are signed by anyone other than the injured party or, if appropriate, the injured party’s parent or guardian will be returned for the required signature. Signature Print Name NORTH CAROLINA COUNTY OF I, , a Notary Public of the County and State aforesaid, do certify that personally appeared before me this day and acknowledged the due execution of the foregoing instrument. Witness my hand and official seal this the day of , 20 . Notary Public Print Name My Commission Expires: PLEASE COMPLETE PAGE 6, MEDICAL EXPENSE CERTIFICATE DELIVERY CERTIFICATION, TO CONFIRM DELIVERY OF YOUR MEDICAL EXPENSE CERTIFICATE.

Required Medical Documentation. This section of the Medical Expense Certificate must be fully completed in order for your claim to be considered. Any corrections or additional information necessary to cure an incomplete Medical Expense Certificate must be submitted to NCSBT within two months of the expiration of the one-year deadline to file a claim. Provide all information required below regarding all medical expenses for which you are seeking reimbursement/payment (i.e., expenses not covered under the insurance, plans, or benefits programs identified above). You must provide updated, itemized medical provider statements which reflect date(s) of service, services rendered, International Classification of Diseases diagnostic codes (ICD-9 or ICD-10 diagnostic codes), charges for services, payments, and any outstanding balances. You must also provide all applicable Explanation of Benefit statements. If additional space is needed, please list on a separate page and attach. “See attached” is not an acceptable response to this section: • Provider Name: Date(s) of Service: Medical Services Rendered: Original Amount of Bill: $ Total Amount Claimed for Payment to Provider of Outstanding Balance: $ Total Amount Claimed for Reimbursement of Out-of-Pocket Expense: $ • Provider Name: Date(s) of Service: Medical Services Rendered: Original Amount of Bill: $ Total Amount Claimed for Payment to Provider of Outstanding Balance: $ Total Amount Claimed for Reimbursement of Out-of-Pocket Expense: $ _ • Provider Name: Date(s) of Service: Medical Services Rendered: Original Amount of Bill: $ Total Amount Claimed for Payment to Provider of Outstanding Balance: $ Total Amount Claimed for Reimbursement of Out-of-Pocket Expense: $ • Provider Name: Date(s) of Service: Medical Services Rendered: Original Amount of Bill: $ Total Amount Claimed for Payment to Provider of Outstanding Balance: $ Total Amount Claimed for Reimbursement of Out-of-Pocket Expense: $ • Provider Name: Date(s) of Service: Medical Services Rendered: Original Amount of Bill: $ Total Amount Claimed for Payment to Provider of Outstanding Balance: $ Total Amount Claimed for Reimbursement of Out-of-Pocket Expense: $ I, , hereby certify that the information provided on this Medical Expense Certificate and the attached documentation represent all true, correct, current, and up-to-date information supporting this claim, and I have completed this form and provided such documentation to the best of my ability. This the day of , 20 . This form must be signed by the injured party or, Signature of Injured Party (if the injured party is a minor, by the injured party’s signature of parent or guardian. Forms that are signed by anyone other than the injured party or, if appropriate, the injured party’s parent or guardian will be returned for the required signature. Signature ) Print Name NORTH CAROLINA COUNTY OF I, , a Notary Public of the County and State aforesaid, do certify that personally appeared before me this day and acknowledged the due execution of the foregoing instrument. Witness my hand and official seal this the day of , 20 . Notary Public Print Name My Commission Expires: PLEASE COMPLETE PAGE 6, MEDICAL EXPENSE CERTIFICATE DELIVERY CERTIFICATION, TO CONFIRM DELIVERY OF YOUR MEDICAL EXPENSE CERTIFICATE.:

Required Medical Documentation. This section of the Medical Expense Certificate must be fully completed in order for your claim to be considered. Any corrections or additional information necessary to cure an incomplete Medical Expense Certificate must be submitted to NCSBT within two months of the expiration of the one-year deadline to file a claim. Provide all information required below regarding all medical expenses for which you are seeking reimbursement/payment (i.e., expenses not covered under the insurance, plans, or benefits programs identified above). You must provide updated, itemized medical provider statements which reflect date(s) of service, services rendered, International Classification of Diseases diagnostic codes (ICD-10 diagnostic codes), charges for services, payments, and any outstanding balances. You must also provide all applicable Explanation of Benefit statements. If additional space is needed, please list on a separate page and attach. “See attached” is not an acceptable response to this section: • Provider Name: Date(s) of Service: Medical Services Rendered: Original Amount of Bill: $ Total Amount Claimed for Payment to Provider of Outstanding Balance: $ Total Amount Claimed for Reimbursement of Out-of-Pocket Expense: $ • Provider Name: Date(s) of Service: Medical Services Rendered: Original Amount of Bill: $ Total Amount Claimed for Payment to Provider of Outstanding Balance: $ Total Amount Claimed for Reimbursement of Out-of-Pocket Expense: $ • Provider Name: Date(s) of Service: Medical Services Rendered: Original Amount of Bill: $ Total Amount Claimed for Payment to Provider of Outstanding Balance: $ Total Amount Claimed for Reimbursement of Out-of-Pocket Expense: $ • Provider Name: Date(s) of Service: Medical Services Rendered: Original Amount of Bill: $ Total Amount Claimed for Payment to Provider of Outstanding Balance: $ Total Amount Claimed for Reimbursement of Out-of-Pocket Expense: $ • Provider Name: Date(s) of Service: Medical Services Rendered: Original Amount of Bill: $ Total Amount Claimed for Payment to Provider of Outstanding Balance: $ Total Amount Claimed for Reimbursement of Out-of-Pocket Expense: $ I, , hereby certify that the information provided on this Medical Expense Certificate and the attached documentation represent all true, correct, current, and up-to-date information supporting this claim, and I have completed this form and provided such documentation to the best of my ability. This the day of , 20 . This form must be signed by the injured party or, if the injured party is a minor, by the injured party’s parent or guardian. Forms that are signed by anyone other than the injured party or, if appropriate, the injured party’s parent or guardian will be returned for the required signature. Signature Print Name NORTH CAROLINA COUNTY OF I, , a Notary Public of the County and State aforesaid, do certify that personally appeared before me this day and acknowledged the due execution of the foregoing instrument. Witness my hand and official seal this the day of , 20 . Notary Public Print Name My Commission Expires: PLEASE COMPLETE PAGE Please complete page 6, MEDICAL EXPENSE CERTIFICATE DELIVERY CERTIFICATIONMedical Expense Certificate Delivery Certification, TO CONFIRM DELIVERY OF YOUR MEDICAL EXPENSE CERTIFICATEto confirm delivery of your Medical Expense Certificate.