Call1-800-362-0700

Would You Like to Submit a Claim?


Call Us to Get Started

If you would like to submit a claim for long-term care insurance benefits, please call our Policyholder Services Department at 1-800-362-0700. Our representatives will send you an information packet containing instructions and required forms for you to complete and mail or fax to us.

 

You can also download and print forms using the links below.

Claim Forms

 TitleDescription
_________________________________ 
1- Assignment of Benefits formThis form authorizes Penn Treaty to pay your home health care agency directly.
2- Attending Physician's StatementThis form is completed by your physician and helps us obtain details about your care requirements. We will contact your physician directly to obtain the completed form; or you may have your physician complete it and submit with other claim forms.
3- Facility Certification of Care formThis form should be used for nursing facility, skilled nursing facility or other facility claims. It should be completed by the facility's administrator or director of nursing.
4- Home Health Care Documentation form instructionsA Home Health Care Documentation form must be completed for each day that services are provided. Call 1-800-362-0700 to request these forms.
5- Monthly Care Certification formThis form should be completed by a facility representative and submitted with an itemized bill each month.

Other Forms

 TitleDescription
6- Address Change Form Use this form to let us know when you change your address and/or phone number.
7- Affidavit - EstateThis form is required to issue any unearned premium refund or benefit payment check to a deceased policyholder’s authorized recipient.
8- Affidavit - TrustThis form is required to issue any unearned premium refund or benefit payment check to a deceased policyholder’s authorized recipient.
9- HIPAA Compliant Authorization to Release InformationPolicyholders must sign this form to give providers permission to release your information to Penn Treaty.
10- Policyholder Authorization to Release Information FormThis form authorizes Penn Treaty to release information about your insurance policy and claim to your representatives.
11- Automatic Bank Draft Authorization formUse this form to have your premium payments automatically deducted from your bank account.
12- Request for Duplicate PolicyUse this form to request a duplicate policy if your original policy has been lost or destroyed. A $25 fee is charged for duplicate policies.