LTC Claims Forms

Claims Forms

Reimbursement

Independent Care Provider Service Bill
If the insured is using an Independent Care Provider, rather than a caregiver employed by an agency, please have the insured and the provider list the itemized charges using the Independent Care Provider Service Bill; use of any other billing format is not eligible for reimbursement for this provider type. Once the form is completed, we ask that the insured submit it to John Hancock.

Direct Deposit Form
If the insured would like to receive reimbursement payments on an active claim via a direct deposit into his/her checking account, complete this form and return it with a copy of a voided check.

Assign Benefits Directly to Provider
If the insured would like to have benefits reimbursement on an active claim made directly to a provider he/she must provide the following:

1.Assignment of Benefits Form (completed by the insured)
The Assignment of Benefits form (AOB) will authorize us to make reimbursement payments for covered services directly to the designated provider. The AOB form (completed by the insured) must be returned with a W-9 Form (completed by the provider).

2.W-9 Form (completed by the provider)
Please note: this W-9 is different from any personal W-9 you may have provided previously to John Hancock. This form needs to contain information about your provider and must be signed by your provider.

Miscellaneous

Fax Cover Sheet
Please use the Fax Coversheet when submitting claim initiation information, request for reimbursement, or other forms in connection with the John Hancock long-term care insurance claim. Including the insured’s name and policy/claim number on the sheet will help us expedite your request.

3rd Party Authorization Form
If the insured would like someone to be able to speak with John Hancock about the long-term care insurance claim, please be sure to complete question 5 of the HIPAA form with the full names.

Note: This only authorizes us to communicate with these parties about your claim. It does not authorize them to sign forms / receive benefit reimbursement on behalf of the insured.

Benefit Eligibility Appeal Form
In the event that the insured wishes to appeal John Hancock’s benefit eligibility decision, after a review of the details provided in the decision, he or she can use this form to provide us with additional information in support of the initial claims request.

Form Signatures

The insured is required to complete and sign all claim forms. However, if the insured wishes to designate someone to make decisions on his/her behalf, the designee must have financial Power of Attorney or Guardianship. That person will then have the right to complete forms related to the claim. We will be unable to process a form signed by someone other than the insured unless we have received Power of Attorney or Guardianship documentation.


Contact Information

John Hancock Insurance Company

ATTN: R-02-B Long-Term Care
PO Box 852
Boston, MA 02117-0852
Phone: 800-233-1449 Fax: 617-572-7979

 Long-Term Care Claims Support

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LTC-2100-38 MLI051915091

Long term care insurance is underwritten by John Hancock Life Insurance Company (U.S.A.), Boston, MA 02117 (not licensed in New York) and in New York by John Hancock Life & Health Insurance Company, Boston, MA 02117.


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