Group Products
Critical Illness and Cancer
Please return completed and signed form by
Insurance Claim Form fax, mail or on-line. Complete Section 1 on the
Physician’s Statement. Your physician must
Metropolitan Life Insurance Company complete the remainder of the Physician’s
Statement (all of Section 2) and return the
completed form to MetLife.
Important Instructions for Requesting Critical Illness and/or Cancer Benefits
• If this is an Initial Claim for an illness, please complete each section in its entirety. (An illness is not
considered reported to us until a claim form is received).
• If this is an additional claim for an illness previously reported (i.e. - initial claim previously submitted and
additional services were incurred), no claim form is required. Please provide supporting documentation
from the healthcare provider related to the critical illness for which a claim is being made.
• Include your claim number and/or certificate number on all pages of your submission.
• Please provide us with supporting documentation from the healthcare provider(s) related to the Critical
Illness for which a claim is being made. The supporting documents MUST include 1) the diagnosis, 2) the
date(s) of diagnosis, and 3) pathology reports, surgical notes, UB 04 forms, lab results, or medical records
that support the diagnosis of the covered condition.
• Examples of medical documentation and information needed based on the patient’s condition:
Important: Not all conditions listed below may be covered under your plan. Please refer to your
certificate of insurance for a listing of the conditions that are covered.
If Your Claim Is for Any of These Conditions Please Include the Following Medical Information With Your Claim
Pathology Reports, Surgical Reports, MRI or CT or other imaging
Benign Tumor
results, medical records that confirm a permanent neurological deficit
Pathology Reports, Surgical Reports, TNM Stage Classification, office
Cancer notes/medical records that show observation of signs, symptoms and
tests that confirm the diagnosis
Cardiovascular Disease, Coronary Artery Disease,
Surgical reports and diagnostic test results showing need for surgery
or Coronary Artery Bypass Graft
Kidney Failure Kidney Specialist records or dialysis records
Functional Loss Clinical records showing the loss has lasted for the required time period
Hospital Summary, EKGs, Cardiac Enzymes. If completed, provide any
Heart Attack of the following: Thallium Scans, Muga Scans, Stress echocardiogram,
Cardiac Catheterization Report
Major Organ Transplant or Major Organ Failure Surgical Report and Clinical Records
Documented Neurological deficits, Neuroimaging studies, Clinical
Stroke
Records and Documentation of deficits 30 days post event
Severe Burn Clinical records showing that the burn covers the required body surface area
Death certificate showing arrest was caused by an underlying heart
Sudden Cardiac Arrest
condition or was the sole cause of death
Childhood Diseases, Infectious Diseases, Listed Specialist records, Lab results, Records showing observation of signs,
Conditions, or Progressive Diseases symptoms and tests that led to the Diagnosis of the condition
Vascular Disease Surgical Reports and Imaging Results
• If the patient is deceased, we will need a copy of the death certificate.
• You must sign and submit the attached Authorization to Disclose Health Information.
• If this claim is for a dependent child, and the Covered Person Specifications page of your certificate states that
dependent children are covered at no additional charge, and you did not need to voluntary enroll in Dependent
Insurance for your dependent child(ren), please submit a birth certificate or other proof of dependent child status.
Failure to complete all sections of this claim form may delay processing this claim. To prevent possible delays,
please be sure to provide all documentation from your healthcare provider that supports this claim. You will be
notified in writing if additional information is needed to process your claim. Please refer to your certificate of
insurance for a listing of specific benefits covered under your plan.
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SECTION 1: Certificateholder Information (Supply information about the certificateholder)
Certificateholder Name
First Name Middle Initial Last Name
SARAH STEVENSON
Address City State ZIP Code
75 BUENA VISTA DR CABOT AR 72023
Certificate Number Date of Birth (mm/dd/yyyy) Gender Social Security Number
B1815737 2/10/1997 Male Female XXXXX5115
Cell Phone Number Daytime Phone Number Evening Phone Number
(501)7335047
Email Address (optional) Employer Name
[email protected] AMAZON.COM SERVICES LLC
SECTION 2: Patient Information (Supply information about the patient.)
Same as Section 1 (If you check this box, you do not need to complete this section. You may skip to Section 3.)
Spouse Child
Patient Name
First Name Middle Initial Last Name
SARAH STEVENSON
Home Address - Street City State ZIP Code
75 BUENA VISTA DR CABOT AR 72023
Date of Birth (mm/dd/yyyy) Gender Social Security Number
2/10/1997 Male Female XXXXX5115
Cell Phone Number Daytime Phone Number Evening Phone Number
(501)7335047
SECTION 3: What Type of Condition Are You Claiming?
• Please provide us with the covered condition for which you are filing a claim. If possible, use the exact name
of the covered condition as it is written in the certificate of insurance.
• We recommend the certificateholder name a beneficiary, if one is not already named, to receive any benefit
that becomes payable if the certificateholder dies. Call 1-800 GET-MET 8 (1-800-438-6388) to request a
beneficiary designation form or visit https://mybenefits.metlife.com.
Describe Condition
Pregnancy hypertension
On what date was the patient first seen for this condition? (mm/dd/yyyy) 07/16/2024
Name of Physician Who Diagnosed the Condition
First Name Middle Initial Last Name
Kala Slaton
Physician Address City State ZIP Code
2300 Robinson ave. Conway AR 72034
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CII-CANCER-CLM-GENERIC-NW (01/21) Fs/f
Confirmed Diagnosis Date (mm/dd/yyyy) 07/18/2024
Has the patient ever been treated for a same or similar condition in the past? Yes No
If “Yes”, when? Please provide details.
If the patient is deceased, check here and provide a copy of the following information:
• Death certificate
• Medical records that document the patient's covered condition
• Autopsy report (if available)
SECTION 4: Special Payment Instructions & Direct Deposits
• If you would like claim benefits paid using direct deposit, please provide the information requested for the
bank where you have your account.
• The sample check below may help you locate your bank account and bank routing numbers. Please be sure
that you are referencing one of your checks, not a deposit or withdrawal slip.
• If a savings account is used, please check with your bank representative for the appropriate routing and
account numbers.
• Use the space below if you need to provide any special instructions. (e.g., requesting that your claim
proceeds be sent to an address other than the address of record).
Would you like claim benefit payments paid using direct deposit? Yes No
(If Yes complete the Account Information section below.)
Bank Name Bank Telephone Number
Arvest (866)9529523
Bank Address - Street City State ZIP Code
75 North East Street Fayetteville AR 72701
Type of account (Check one): Checking Savings
Be sure to confirm your account and routing
numbers with your bank to ensure prompt
processing.
Bank Routing Number
082900872
Bank Account Number
55214210
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Authorization & Signature of Certificateholder
• I request MetLife to send my payments to the financial institution designated in Section 4 for deposit into my
account. This agreement will remain in effect until MetLife receives notice from me to the contrary.
• I understand that MetLife will not be liable for any failure to change or terminate this agreement until a
written request is received from me in satisfactory form and reasonable time has passed for MetLife to act
upon it.
• If any overpayment is credited to my account in error, I authorize and direct my financial institution to debit
my account and to refund such overpayment to MetLife.
Name (Please print)
First Name Middle Name Last Name
SARAH STEVENSON
Signature of Certificateholder Date (mm/dd/yyyy)
Electronically Signed by Sarah Michele Stevenson 07/25/2024
SECTION 5: Fraud Warnings
Before signing this claim form, please read the warning for the state where you reside and for the state where
the insurance policy under which you are claiming a benefit was issued.
Alabama, Arkansas, District of Columbia, Louisiana, Massachusetts, Minnesota, New Mexico, Ohio,
Rhode Island and West Virginia: Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime
and may be subject to fines and confinement in prison.
Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a
claim containing false, incomplete or misleading information may be prosecuted under state law.
Arizona: For your protection, Arizona law requires the following statement to appear on this
form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is
subject to criminal and civil penalties.
California: For your protection, California law requires the following to appear on this form: Any person who
knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject
to fines and confinement in state prison.
Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an
insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include
imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance
company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a
settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance
within the Department of Regulatory Agencies.
Delaware, Idaho, Indiana and Oklahoma: WARNING: Any person who knowingly, and with intent to injure,
defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false,
incomplete or misleading information is guilty of a felony.
Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a
statement of claim or an application containing any false, incomplete or misleading information is guilty of a
felony of the third degree.
Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a
statement of claim containing any materially false information or conceals, for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
Maine, Tennessee and Washington: It is a crime to knowingly provide false, incomplete or misleading
information to an insurance company for the purpose of defrauding the company. Penalties may include
imprisonment, fines or a denial of insurance benefits.
Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or
benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime
and may be subject to fines and confinement in prison.
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New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a
statement of claim containing any false, incomplete, or misleading information is subject to prosecution and
punishment for insurance fraud as provided in RSA 638:20.
New Jersey: Any person who knowingly files a statement of claim containing any false or misleading
information is subject to criminal and civil penalties.
Oregon: Any person who knowingly presents a materially false statement of claim may be guilty of a criminal
offense and may be subject to penalties under state law.
Puerto Rico: Any person who knowingly and with the intention to defraud includes false information in an
application for insurance or files, assists or abets in the filing of a fraudulent claim to obtain payment of a loss or
other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty
shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten
thousand dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating
circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating
circumstances are present, the jail term may be reduced to a minimum of two (2) years.
Texas: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a
crime and may be subject to fines and confinement in state prison.
Vermont: Any person who knowingly presents a false statement of claim for insurance may be guilty of a
criminal offense and subject to penalties under state law.
Virginia: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer,
submits an application or files a claim containing a false or deceptive statement may have violated the state law.
Pennsylvania and all other states: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for insurance or statement of claim containing any materially false
information or conceals for the purpose of misleading, information concerning any fact material thereto commits
a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
SECTION 6: Certification & Signature
By signing below, I acknowledge:
1. All information I have given is true and complete to the best of my knowledge and belief.
2. I have read the applicable Fraud Warning(s) provided. New York residents: Any person who knowingly
and with intent to defraud any insurance company or other person files an application for insurance or
statement of claim containing any materially false information, or conceals for the purpose of misleading,
information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and
shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim
for each such violation.
Under penalty of perjury, I certify:
1. That the number shown on this form is my correct taxpayer identification/social security number;
and
2. That I am not subject to IRS required backup withholding as a result of failure to report all interest
or dividend income; and
3. I am a U.S. citizen, or a U.S. resident for tax purposes.
Please note: If item 2 or 3 above is not true, cross out the applicable item(s). The IRS does not require
your consent to any provision of this document other than the certification to avoid backup withholding.
Signature of Certificateholder or Authorized Representative Date (mm/dd/yyyy)
Electronically Signed by Sarah Michele Stevenson 07/25/2024
Name of Certificateholder or Authorized Representative, if Applicable (Please print)
First Name Middle Initial Last Name
SARAH STEVENSON
If signed by Authorized representative, describe your authority and provide documentation.
Insured
(e.g., guardian, conservator, power of attorney, etc.)
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Group Products
Authorization to Disclose Health Information
Metropolitan Life Insurance Company
Things to Know Before You Begin
Your refusal to complete and
• Instructions for completing the form: complete all applicable sign this form may affect your
areas of the form and sign below. eligibility for benefits under
• If you are the Authorized Representative, include a copy of the your critical illness or cancer
legal document(s) authorizing you to act on the Patient’s behalf. insurance policy.
HIPAA: This Authorization has been carefully and specifically drafted to permit disclosure of health
information consistent with the privacy rules adopted and subsequently amended by the United States
Department of Health and Human Services pursuant to the Health Insurance Portability and
Accountability Act of 1996 (HIPAA).
For purposes of determining my eligibility for Critical Illness or Cancer benefits, the administration of my critical
illness or cancer benefit plan, and the administration of other benefit plans in which I participate that may be
affected by my eligibility for critical illness or cancer benefits, I permit the following disclosures of information
about me to be made in the format requested, including by telephone, fax or mail:
1• I permit: any physician or other medical/treating practitioner, hospital, clinic, other medical related facility or
service, insurer, employer, government agency, group policyholder, contractholder or benefit plan
administrator to disclose to Metropolitan Life Insurance Company (“MetLife”), my employer in its capacity as
administrator of its critical illness or cancer benefit plan, and any consumer reporting agencies, investigative
agencies, attorneys, and independent claim administrators acting on MetLife’s behalf, any and all
information about my health, medical care, employment, and critical illness or cancer claim.
2• I permit MetLife and my employer (if applicable) to disclose in its capacity as administrator of its benefit
plans any and all information about my health, medical care, employment, and critical illness or cancer
claim.
This Authorization to Disclose Health Information specifically includes my permission to disclose my entire
medical record, including medical information, records, test results, and data on: medical care or surgery;
psychiatric or psychological medical records, but not psychotherapy notes; and alcohol or drug abuse including
any data protected by Federal Regulations 42 CFR Part 2 or other applicable laws. Information concerning
mental illness, HIV, AIDS, HIV related illnesses and sexually transmitted diseases or other serious
communicable illnesses may be controlled by various laws and regulations. I consent to disclosure of such
information, but only in accordance with laws and regulations as they apply to me. Information that may have
been subject to privacy rules of the U.S. Department of Health and Human Services, once disclosed, may be
subject to redisclosure by the recipient as permitted or required by law and may no longer be covered by those
rules. Your health care provider may not condition your treatment on whether you sign this authorization.
I understand that I may revoke this authorization at any time by writing to MetLife Group Critical Illness or
Cancer at P.O. Box 80826, Lincoln, NE 68501-0826, except to the extent that action has been taken in reliance
on it. If I do not, it will be valid for 24 months from the date I sign this form or the duration of my claim for
benefits, whichever period is shorter. A photocopy of this authorization is as valid as the original form and I have
a right to receive a copy upon request.
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Name of Patient (Please print)
First Name Middle Initial Last Name
SARAH STEVENSON
Date of Birth (mm/dd/yyyy) Social Security Number
2/10/1997 XXXXX5115
Signature of Patient or Authorized Representative Date (mm/dd/yyyy)
Electronically Signed by Sarah Michele Stevenson 07/25/2024
If signed by Authorized representative, print your name, and describe your authority and provide
documentation.
Insured
(e.g., guardian, conservator, power of attorney, etc.)
How to Submit This Form
Mail: Toll Free Phone: Fax:
Cancer/Critical Illness Insurance Products 1 866 626 3705 1 855 306 7350
P.O. Box 80826
Lincoln, NE 68501-0826 https://mybenefits.metlife.com
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