Medical Claim Forms

To request reimbursement of incurred medical expenses or to seek preapproval of medical care, you must submit a claim or preapproval request to your health care insurance first. For detailed information, review these instructions.

Submit all charges first to the health insurance plans in which you have coverage. Only the amounts not covered by insurance can be claimed through the Disability Board.

All completed claims need to be received in the Board office by the second Wednesday of the month in which you want them reviewed.

• Form 5   / Form 5 (fill-in) (employer’s form). This form needs to be completed by the employer and attached to your claim before it is submitted to the Board for review.
  
• Form 6 / Form 6 (fill-in) (LEOFF-1 member's form). Every medical and alternative health care claim must have a Form 6 completed by you. Fill in all blanks, including a list of service dates, name of medical provider and total dollar amount of charges left after insurance.
  
• Form 7 / Form 7 (fill-in) (health care provider's form). All medical/health care/vision claims need Form 7 as documentation from the physician or therapist (omitted for long-term care, assisted living, in-home care and hospice). Ask your physician or health care provider to complete all sections, sign and date the form, and return it to you.
  
• Form 8 / Form 8 (fill-in) (treatment plan). A provider may use this form in place of a written treatment plan for the following treatments (either a written treatment plan or Form 8 is required for all of these services): acupuncture/acupressure, massage therapy, smoking cessation, mental health, chiropractic care and substance abuse.  
• Form 9 / Form 9 (fill-in) (nursing home/assisted care facility form). This form replaces Form 7 and Form 8 when applying for reimbursement of costs incurred for nursing home or assisted care. This form needs to be completed by the responsible family member/legal representative as well as by the director of nursing and medical director or primary physician.
  
• Form 10A / Form 10A (fill-in); Form 10B / Form 10B (fill-in); 
  Form 10C / Form 10C (fill-in) (home health care forms). These forms replace forms 7, 8 and 10 when applying for reimbursement of costs for in-home care. Please follow the directions on each form when submitting your claim for reimbursement..