Use this form to give MetLife permission to share with a third party protected health information relating to your long-term care coverage. The information shared could include demographics, billing, and policy/plan information, and might be used for insurance, continued medical care, or other reasons. You do not have to sign this form, as it is voluntary. We will not release protected health information to a third party unless you have signed a form specifically instructing us to do so.
Automatic Premium Deduction Request Form
Use this form to request that your monthly long-term care insurance premium be automatically deducted from your checking or savings account. This form may also be used to provide us with an update, should your bank account details change.
Provider Payment Guide & Invoice Forms
If your eligibility claim to receive benefits has been approved, you would have received by mail instructions on how to submit invoices for reimbursement. For your convenience, we have provided the payment guides below. Select the appropriate guide to download 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 been incurred.
NOTE: Refer to the letter you received when your eligibility claim was approved, to select the correct guide.
Provider Payment Guide & Invoice (Informal)
Provider Payment Guide & Invoice (Independent)
Provider Payment Guide (If your care is provided for via Home Care)
Provider Payment Guide (If your care is provided by a Facility)
Direct Deposit Forms (For Reimbursement of Claims)
If your claim for reimbursement has been approved and you would like the reimbursement direct deposited to your (the insured’s) bank account, please complete and return the appropriate Direct Deposit Form. You may also use the same form to enroll or change your direct deposit information. If you need clarification as to whether you have an individual or group policy, please review the “Can’t Find Your Answer?” section at the bottom of the page.
NOTE: If you are unable attach a voided check at this time, please make use of Section 2 of the form to provide us with the Insured Name, Check Routing Number, and Checking Account Number.
Direct Deposit Form – Individual
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.
Assignment of Benefits
To have reimbursement made directly to a provider, instead of yourself, you’ll need to complete the Assignment of Benefits form. Please note, reimbursement for your long-term care expenses can only be made to you, your estate, or the provider administering your covered long-term care services.
Address Change for Insureds in Claim
Please call Customer Service to have your information updated in our systems. Or, complete and return our address change form.
Address Change for Insureds NOT in Claim
Complete and return our address change form to have your information updated in our system.