ULTIMATE HEALTH
by ArmadaCare
Underwritten by
TRANSAMERICA
Ultimate Health Insurance Claim Form
Submit Claims Online for Faster Processing: Visit www.ArmadaCare.com/myaccount.
For log-in information, contact Member Services at 1-855-943-4595.
For detailed instructions on completing this form, be sure to:
• Include supporting documentation, such as primary medical, dental or vision insurance EOB.
• Attach supporting documentation in the same order as you list the claims on this form.
• Be sure to limit claims to five (5) per form. Use a separate claim form for each policy year.
Policy Information
Primary Insured Name: Robert Hawkins
Date of Birth (DOB): 04/18/1959
Policyholder/Employer: Lakeshore Cardiology
Phone: (312) 555-0148
Email: robert.hawkins@gmail.com
Claim Information
Date of ServiceDiagnosis / ReasonEligible ExpensePrimary Carrier
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Plan approved: $430.18
Patient balance: $211.82
Authorization
I authorize any doctor, hospital or other medically related facility, insurance company or other organization having records or knowledge of me or my health to disclose, whenever requested to do so, all information with respect to any illness or injury, medical history, consultation, prescriptions or treatment, and copies of all hospital or medical records. This authorization is valid for one year from the date shown below.
Robert Hawkins
Insured's Signature
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