Hospital Confinement Indemnity and Wellness Benefit Claims

Hospital Confinement Indemnity Insurance Claim

Please distribute the following forms to the insured.

  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: If the Employer has submitted enrollment data electronically, this form does not need to be completed.
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)

Wellness Benefit Claim

Please distribute the claim form to the insured. The Consumer Privacy Notice is attached.

Form NameForm Number

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

167779 (06/25/2013)