F00892 Claim For Hospital And Other Medical Expenses

Instructions:  

Welcome to the World Bank Group HR Forms Instructions page.

This form filler tool is designed to assist you in electronically entering your data and printing a paper form with a unique barcode corresponding to your entered data. Once you've completed your answers and printed the form, you'll need to submit it either by email or in person, depending on the form type.  Please note that the data you enter is directly captured in the form's unique barcode, so it's important that you do not make any handwritten changes, corrections, or additions to the data or to the form after it has been printed. Doing so may result in data errors and processing delays.

In case you notice any errors after printing your form, or if you've left a field blank, we recommend starting over and completing a new form. It's also important to remember that your information is not saved by the form filler and can no longer be accessed after you print it. Therefore, please be extra careful in reviewing your answers, as it is impossible to make any corrections after the form is printed.

Each form will take approximately ten minutes to complete. Please ensure you have the needed documents such as passport to extract information that may be required in some fields. Do not close the forms until they are ready for a download. Partially filled forms cannot be saved to be completed later. If you need further assistance, please contact. Thank you!

Information on Completing the Form

1)  If illness or injury occurred while at work, contact the Workers Compensation Insurance Representative, ext. 30807, BEFORE filling out this form.

2)  Return completed form to: mclaims@aetna.com OR Aetna/World Bank MIP Claims P.O. Box 14199 Lexington, KY 40512-4199 USA OR via internal mail to MIP Claims MSN MC-C3-309.

Need Help? 

If you are experiencing any issues, please contact HR Operations via email: hroperations@worldbank.org  or phone 202-473-2222 or 5220+32222.

Revision 26 Jan 2024

Part I - To Be Completed by Staff Member or Retired Staff Member (Hereinafter: Staff Member) or Patient If Covered Separately from Staff Member

1.Patient's Name (Last, First, M.I.)*

2. Patient's Relationship to Staff Member*

3. Patient's Birthdate*

4. Sex*

5. If claim is for son/daughter, was the child under age 26 at the time the expense was incurred?*

6. Staff Member's (or surviving Spouse's) Name (Last, First, M.I.) - IF NOT PATIENT

7. Staff Member's (or Surviving Spouse's) Birthdate - IF NOT PATIENT

8. Staff Member's UPI No.*

9. Nature of illness, injury or service*

10. If claim is for accidental injury, enter date and indicate where and how occured

11. Is claim for second surgical opinion?

12. Is patient, other than staff member, employed?*

13. Name and Address of Employer in Item 12*

14. Is patient covered by another group, student, government (e.g. Medicare) or employment related Medical Plan?*

Medical Plan NameThe text will appear here*

Group No.*

Name and Address of Carrier*

I authorize the release to the World Bank Group Medical Insurance Plan administrator, to the World Bank Group or their representative, any information including medical, employment and benefit information required for claim processing or plan administration. Such information shall be released directly to the World Bank Group only in circumstances where fraud or misconduct is believed to have occurred. This authorization to release information is valid for two years after the date signed. A copy of this authorization shall be as valid as the original. If the staff member is incapacitated or deceased, the Personal Representative or next of kin must sign.

Patient's Signature (Parent/Guardian, if minor; leave blank if staff member) 

Date (mm/dd/yyyy)

I certify that the statements here and attached are complete and accurate. As the patient, I authorize the release of information as described above.

Staff Member's Signature

Date (mm/dd/yyyy)

Part II - To Be Completed by Attending Physician (In Lieu of Itemized Bill)

15. Physician's Name (Last, First, M.I.)*

16. Mailing Address (Street, City, State, Postal/Zip Code)*

17. Is treatment result of occupational illness or injury?*

Enter brief description and dates*

18. Date symptoms first appeared or accident happened*

19. Physician's S.S.N. or T.I.N.

20. Physician's License No.

21. Physician's Telephone No.*

22. Date you were first consulted on this condition?*

23. Diagnosis and current condition*

24. Has patient ever had same or similar condition?

If Yes, indicate when and describe*

25. Is patient still under your care for this condition?
Date of Service
Place
ICD-9 Code
Description
Charge

After filling this document, you must sign and date it before returning this document. Please ensure ALL information in the submission form is complete and accurate before printing the form. This will generate your form(s) as a PDF file. Review the file for accuracy and completeness. If there is an error, please start a new form. 

Return completed form to: mclaims@aetna.com OR Aetna/World Bank MIP Claims P.O. Box 14199 Lexington, KY 40512-4199 USA OR via internal mail to MIP Claims MSN MC-C3-309.