EUTF Claim Form

Plan Year: July 1, 2018 to June 30, 2019.

The filing deadline for dates of service between July 1, 2018 and June 30, 2019 is October 28, 2019 or 120 days after your termination date, whichever is earlier. The plan will not pay any claims received after the filing deadline.

Please follow the Claim Filing Requirements. Complete the information below for medical care and/or prescription drug expenses that were incurred by you or your eligible dependents. The services must have been paid by your primary health insurance plan to be eligible for reimbursement. Failure to complete the required information on this form or follow the Claim Filing Requirements will result in a delay in processing your claim.

EUTF ONLINE CLAIM FORM

Employee Name*
Enter the employee name of the primary EUTF subscriber.
First Name M.I. Last Name
Email Address*
Phone Number*

Services Reimbursement*

Complete all the information requested on the claim form. Please submit a photocopy of your claim form and supporting documents because submitted documents will not be returned to you. Additional claim forms are available at www.hma-hi.com/eutf or upon request.

Date of Service	Name of Person Receiving Service	Date of Birth	Description of Service	Amount

Reimbursement of medical services*
For reimbursement of medical services and/or prescription drugs, please attach your insurance payment reports (e.g., HMSA Report to Member) or Explanation of Benefits statements from your primary health insurance plan. If your primary health insurance plan is with Kaiser Permanente, please attach your copayment receipts. Billing statements and payment receipts from your health care provider will not be accepted. For prescription drugs, attach insurance payment reports or prescription drug receipts from your pharmacy that shows the patient’s name, physician’s name, Rx number, drug name, date of service and amount of copayment.
Drop files here or
Acknowledgment*
To the best of my knowledge, the information on this Claim Form is complete and true. I certify that these are eligible medical care and/or prescription drug expenses that my dependents or I have incurred. I understand that these expenses must qualify as benefits under the EUTF Supplemental Health & Pharmacy Plan, and cannot be reimbursed by any other source or used as a deduction on my personal income tax return. I have read and followed the claim filing requirements on the back of this form.
- I Agree
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