Your provider will use this form to get your permission to share your protected health information to a third party for personal use, insurance, continued medical care, or other reasons. You do not have to sign this form as it is voluntary. Failure to sign the authorization form will result in the non-release of the protected health information.
Use this form to request an automatic monthly premium deduction from your checking, savings, or individual business account. You may also use this form to update your bank account information when you are having premiums deducted from your specified account.
If your claim has been approved, you can use the payment guides listed below based on the level of care you are receiving during your eligibility period. These forms are used for reimbursement purposes and outline the documents necessary to help facilitate the processing of your reimbursement. Please do not submit invoices until services have incurred.:
Please submit your request for reimbursement by one method only. Duplicate submissions of the same invoice will delay claims processing. Invoices may be submitted by email to email@example.com, by fax to 1-866-722-1180, or by mail to MetLife Long-Term Care, P.O. Box 14407, Lexington, KY 40512-4633. Payment is generally processed within ten business days after we receive completed forms.
If your claim has been approved and you would like the reimbursement direct deposited to the insured’s bank account, please complete and return the one of the following direct deposit forms. You can use this form to enroll or change your direct deposit information. If you need clarification, you may contact your Care Coordinator with any questions:
Use this form to enroll in direct deposit or change your direct deposit information.
Use this form if you would like to designate someone in addition to yourself to receive a copy of the final billing notice.