HEALTH INSURANCE RESPONSE FORM – PRE-EXISTING CONDITION

Thank you for selecting the TII Global Student Medical Plan. HealthSmart is the claim administrator of your plan.
We have received a medical bill from your doctor and need additional information from you in order to complete our processing of your claim.
Claims are formal requests for the plan to pay for services you’ve utilized, usually submitted by the providers you see.
Please provide the information listed below.
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6. During the period specified under the Remarks Code Section on your Explanation of Benefits (EOB) have you consulted any physicians? *
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HealthSmart
PO Box 94468| Lubbock, TX  79493-4468 | 833-782-5090 (phone) | 806-473-3136 (fax)