File a Medical Claim
Submit a Claim by Mail
It’s easy! Just download the claim form below. Fill out the first page with your personal information, dates of injury or sickness, the cause of the injury or date of first symptoms for a sickness, sign your name with today’s date, and attach all receipts. Please fill out the entire first page and be sure not to leave anything blank.
Your doctor will need to fill out the second page of the form.
Mail Claim Forms to:
P.O. Box 809025
Dallas, TX 75380-9025
Submit a Claim Electronically
Your Doctor can also submit a claim electronically using Emedeon (formerly WebMD). This gives a faster turn-around time than submitting a claim by mail. Check with your doctor to see if they are a participant. If they are, show them your ID Card. The Emedeon information is printed on the back of every ID Card.