Hospital Confinement Indemnity and Wellness Benefit Claims

You may be eligible to receive a Hospital Confinement Indemnity Benefit and/or Wellness Benefit under your Hospital Confinement Indemnity Insurance certificate. Please review your certificate and riders for the eligibility requirements to receive benefits.

To submit a Hospital Confinement Indemnity Insurance Claim, please print the following forms below:

  1. Compass Hospital Confinement Indemnity Claim - Employee Form. The Consumer Privacy Notice is attached.
  2. Attending Physician's Statement of Hospital Confinement Indemnity

  3. Authorization to Release Information
  4. Hospital Confinement Indemnity Claim – Employer form. The Consumer Privacy Notice is attached. 
    Note: Please contact your Employer to determine whether the Hospital Confinement Indemnity Claim – Employer form is required.

Submit the completed and signed claim form, attending physician's statement, and authorization form to the address shown at the top of the form.

Form NameForm Number

Compass Hospital Confinement Indemnity Claim - Employee (with Consumer Privacy Notice 47316c attached)

167313 (2/7/14)

Attending Physician's Statement of Hospital Confinement Indemnity

167314 (2/7/14)

Authorization to Release Information

132542 (09/30/2009)

Hospital Confinement Indemnity Claim - Employer (with Consumer Privacy Notice 47316c attached)

167546 (2/7/14)

To submit a Wellness Benefit Rider Claim:

Please print the Hospital Confinement Indemnity Wellness Benefit Rider Claim form below. The Consumer Privacy Notice is attached.

Submit the completed and signed form to the address shown at the top of the form, along with any other required information such as itemized bill(s) or Explanation of Benefits (EOB).

Form NameForm Number

Hospital Confinement Indemnity Wellness Benefit Rider Claim - Employee (with Consumer Privacy Notice 47316c attached)

167779 (06/25/2013)

n/a