| Title |
|
|
pdf
AmeriCorps NCCC Health Benefit Plan Guide
- This guide provides an overview of the AmeriCorps Health Benefit Plan as well as how to use your benefits for covered medical expenses.
|
Download
|
|
pdf
AmeriCorps NCCC Health Benefit Plan Guide (español)
- Esta guía proporciona una visión general del Plan de Beneficios de Salud de AmeriCorps y como usar sus beneficios para los gastos médicos que están cubiertos.
|
Download
|
|
pdf
Coverage Information Form
- In order for IMG to accurately process your medical claims and ensure that you receive the maximum benefits available, you must complete this form at the beginning of each service term and/or whenever there is a change in your other coverage status. Please note: You may also submit your information online via your MyIMGNCCC account.
|
Download
|
|
pdf
Coverage Information Form (español)
- A fin de que IMG pueda procesar correctamente sus reclamos y garantizar que usted reciba los máximos beneficios disponibles, este formulario se debe proporcionar a IMG al comienzo de cada nuevo período de servicio y/o cuando haya cambios en su estado de cobertura de gastos médicos. Nota: También puede acudir a su cuenta en línea de MyIMGNCCC para proporcionar esta información.
|
Download
|
|
pdf
Health Benefit Plan Claim Form
- If you are covered under the Health Benefit Plan and you have paid for medical services out-of-pocket, this form must be completed and returned to IMG along with a detailed bill and/or payment receipts.
|
Download
|
|
pdf
Health Benefit Plan Claim Form (español)
- Si usted pagó por servicios médicos de su bolsillo, debe proporcionar este formulario a IMG junto con la(s) factura(s) detallada(s) del proveedor, recibos de pago y la Explicación de Beneficios (EOB) de otros seguros (si corresponde).
|
Download
|
|
pdf
ACH Wire Transfer Form
- If you wish to have any reimbursements payable to you to be directly deposited into your account, you may fill out this form, and the information will be securely kept on file. If you need to make a change, simply submit a new form.
|
Download
|
|
pdf
ACH Wire Transfer Form (español)
- Si desea que IMG use Depósito Directo para enviar un reembolso por reclamos médicos u otros gastos médicos reembolsables que usted pago como miembro, debe proporcionar este formulario a IMG y la información será mantenido en un archivo protegido. Si necesita hacer un cambio, sólo tiene que proporcionar un nuevo formulario.
|
Download
|
|
pdf
Injury and Accident Form
- If medical treatment was sought due to an injury or accident, you will need to submit this form to IMG in order for us to process the related claims.
|
Download
|
|
pdf
Injury and Accident Form (español)
- Si usted recibió tratamiento médico debido a un accidente o una lesión, tendrá que proporcionar este formulario a IMG con el fin de que podamos procesar los reclamos relacionados.
|
Download
|
|
pdf
Subrogation Agreement
- If you are covered under the Health Benefit Plan and a third-party is considered the cause of or is at-fault for your accident, injury, etc., then this form must be completed, signed and submitted to IMG.
|
Download
|
|
pdf
Subrogation Agreement (español)
- Si un tercero se considera la causa o el culpable de su accidente, lesiones, etc., debe proporcionar este formulario a IMG.
|
Download
|
|
pdf
Privacy Confidentiality Release Form
- In order for IMG to discuss your claims activity with anyone other than you and your physician(s) or provider(s) of service, for example a parent or spouse, you must complete this form and submit it to us.
|
Download
|
|
pdf
Privacy Confidentiality Release Form (español)
- A fin de que IMG pueda compartir sus actividades de reclamos con alguien que no sea médico o proveedor de servicios médicos, por ejemplo, un padre o cónyuge, debe proporcionar este formulario a IMG.
|
Download
|
|
pdf
Prescription Direct Mail Enrollment Form
- This form can be used to have your prescription medications & refills delivered directly to your home. NOTE: For your convenience, we recommend enrolling online at https://www.envisionpharmacies.com/mail or calling to 866-909-5170.
|
Download
|
|
pdf
Domestic Volunteer Service Act AmeriCorps Secondary Not Insurance
- The health benefit provided by AmeriCorps to its volunteer members is secondary to all commercial insurance, including when the AmeriCorps Member is listed as a dependent on a commercial product.
|
Download
|
