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Important Documents & Forms

Privacy Authorization form

Your provider will use this form to get your permission to share your protected health information with 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. If you do not sign the authorization form, we will not release protected health information to a third party. 

Please complete the form and email it to longtermcareclaims@metlife.com. You may also fax it to 1-866-722-1180 or mail it to:

MetLife Long Term Care Claims
PO Box 14407
Lexington, KY 40512

Automatic Deduction request form

Automatic Deduction request form (Checking/Savings)

Use this form to request an automatic monthly premium deduction from your checking or savings account. You may also use this form to update your bank account information when you are having premiums deducted from your specified account.

Please mail the completed form to the following address:

MetLife LTC
P.O. Box 14634
Lexington, KY  40512-4634

Provider Payment Guide & Invoice

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:

Direct Deposit form & Fraud language (Individual)

If your claim has been approved and you would like the reimbursement direct deposited to the insured’s bank account, please complete and return 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.

You may fax the completed form to 1-866-722-1180. You may also mail it to the following address:

MetLife Long-Term Care
Claims ACH Processing Center
P.O. Box   14407
Lexington, KY 40512-4633

Direct Deposit form & Fraud language (Group)

If your claim has been approved and you would like the reimbursement direct deposited to the insured’s bank account, please complete and return 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.

You may fax the completed form to 1-866-722-1180. You may also mail it to the following address:

MetLife Long-Term Care
Claims ACH Processing Center
P.O. Box   14407
Lexington, KY 40512-4633

Lapse Designee Form

Use this form if you would like to designate someone in addition to yourself to receive a copy of the final billing notice.