CLAIM FORM FOR MEDICAL BENEFITS
AGVA WELFARE TRUST FUND
363 Seventh Avenue ~ 17th Floor
New York, NY 10001-3904
(212) 627-4820 ~ AGVAUSA.com
PLEASE PRINT LEGIBLY AND RETURN THIS FORM WITH ORIGINAL DOCTOR BILLS* & RECEIPTS
~ALL CLAIMS MUST CONTAIN DIAGNOSIS AND PROCEDURE CODES~
DATE______________________________________
LAST NAME_____________________________________________FIRST NAME______________________________________________
STAGE NAME____________________________________________________________________________
ADDRESS____________________________________________________________________________________APT-_________________
CITY_________________________________________STATE___________________________________ZIP CODE___________________
DATE OF BIRTH (mm/dd/yyyy)________/________/_____________ SEX (circle to indicate) Female Male
SOCIAL SECURITY #___________-______-___________AGVA MEMBERSHIP # _____________________________________________
PHONE (______)__________-________________CELL(______)___________-___________________
EMAIL ADDRESS____________________________________________________________________________________________________
MOST RECENT AGVA PERFORMANCE (Group & Venue) & DATE:___________________________________________________________
OTHER HEALTH CARE INSURANCE (name of plan, address, policy & group #s)________________________________________________
____________________________________________________________________________________________________________________
WAS CONDITION RELATED TO: EMPLOYMENT- yes no AN AUTO ACCIDENT- yes no
PLEASE SIGN WHERE INDICATED BELOW:
I hereby authorize my provider to release information, as necessary, to AGVA Welfare Trust Fund in order to process this claim.
I hereby certify that the above statements are complete and accurate to the best of my knowledge. I also agree to reimburse The AGVA Welfare Trust Fund to the extent of any overpayment which is in excess of the amounts payable under the benefit plan.
SIGN HERE (for ALL claims):____________________________________________DATE________________
Sign here to pay provider _________________________________________________DATE________________
Sign here to pay insured __________________________________________________DATE________________
WTF ONLY: DED PHCS MULTIPLAN NYCOV NYHOSP EFFDT ___________ EXPDT___________ INIT
WTF COMMENTS: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
ANY PERSON WHO KNOWINGLY (AND WITH INTENT TO INJURE) DEFRAUDS OR DECEIVES ANY INSURANCE COMPANY, FILES A STATEMENT OF
CLAIM CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION MAY, BE GUILTY OF A CRIMINAL ACT PUNISHABLE UNDER LAW.
*please note that the doctor’s medical credentials must be indicated on his/her submitted bill (ie.: MD, DC)
~ONLY ONE FORM NECESSARY PER MAILING OF MULTIPLE BILLS~