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The Shelter Care Claim form plays an essential role in helping pet owners secure financial assistance for their beloved animals' medical needs. This form, underwritten by Praetorian Insurance Company, New York, is specifically designed to ensure that the claims process is both thorough and efficient. It is crucial to fill out every section of the form completely, as missing information can lead to delays in processing. Pet owners must attach a paid itemized invoice along with their pet's veterinary medical history from both current and previous veterinarians. The claims process requires clear and accurate documentation, including detailed examination notes, lab reports, and specific invoices that outline the treatments provided. To assist both pet owners and veterinarians, a Claims Checklist is included, guiding them through the necessary steps, from filling out personal information and pet details to obtaining the veterinarian's diagnosis and signature. By adhering carefully to these guidelines, pet owners can help facilitate timely and fair claims, ensuring that they receive the support they need when caring for their pets.

Shelter Care Claim Example

Claim Form

Underwritten by Praetorian Insurance Company, NY

INSTRUCTIONS: Please complete ALL sections on this form and submit with your paid itemized invoice and pet’s medical history. Only one claim form per pet. A complete veterinary medical history (records) from both current and previous veterinary clinics is required to process your pet’s ollow the Claims Checklist to avoid delays in processing.

Claims Checklist

Complete Section 1 About You and Your Pet

Include your Policy Number

Include your Contact Information

Review your Policy Documents and Terms and Conditions to see if coverage is available for the current medical condition you are claiming for

Have the treating veterinarian complete Sections 2 and 3

Sign your claim form in the Declarations Section (Section 3) Attach detailed paid invoices for condition(s) you are claiming for

*Missing information, signatures, or required supporting documents will result in delays in processing your claim

Medical Records Include:

Detailed examination or SOAP notes

Lab/pathology/radiology reports

Medical reports from referral or emergency hospitals

Transaction histories and invoices are not accepted

Invoices Must Be:

Detailed and Itemized indicating the cost and treatment

Paid, unless reimbursement is to be made and agreed to by the veterinarian Account Summaries are not accepted

SECTION 1A: Your Pet’s Information

Policy Number:

Pet Name:

 

 

 

Species: Dog

Cat

Breed:

 

Age:

 

 

SECTION 1B: Your Information

Your Name:

Mailing Address:

Email Address:

Home Number:

Cell Number:

Check here if there has been a change to your address or phone number

SECTION 2: About Your Claim To be completed by the treating licensed Veterinarian

Diagnosis

List each separate diagnosis clearly

1

2

3

Date

of

ns and

Total amount

Has this medical condition been

 

 

symptoms

(as noted by you, the

being claimed:

treated previously?

 

 

 

client or the pet’s medical record)

 

 

 

 

 

 

 

 

 

 

 

 

 

$

Yes

No

When:

 

 

 

 

 

 

 

 

 

 

 

 

MM

DD

YY

 

 

 

 

MM

DD

YY

 

 

 

 

 

$

Yes

No

When:

 

 

 

 

 

 

 

 

 

 

 

 

MM

DD

YY

 

 

 

 

MM

DD

YY

 

 

 

 

 

$

Yes

No

When:

 

 

 

 

 

 

 

 

 

 

 

 

MM

DD

YY

 

 

 

 

MM

DD

YY

Veterinarian Notes Please also attach veterinary history, radiology, pathology reports, and consultation notes where applicable

Pet’s Weight:

 

KG LB

Body Condition Score (BSC):

 

 

 

1-5 Scale (1=Emaciated, 5=Obese)

1-9 Scale (1=Emaciated, 9=Obese)

When was this pet registered with your practice?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM DD YY

If this pet was referred to you, please give the name of the referring practice:

SUBMIT A CLAIM

Email medicals@pethealthinc.com

Fax: 1.866.369.7387

Continue to Page 2

 

 

 

 

SECTION 3: Declarations

Policyholder Declaration

Veterinarian Declaration

I declare that my veterinarian recommended the treatment for which I am claiming. The veterinary clinic has completed Section 2 and the particulars given are correct to the best of my knowledge and belief. I agree that my veterinarian may provide information that the company may require to verify a claim. I understand that any misrepresentation or omission of any material fact can result in denial of the claim and I conm my understanding of the applicable fraud warning below.

I declare that diagnosis and particulars given in Section 2 in regards to the treatment of this pet are correct to the best of my knowledge and belief. I agree to provide information that the company may require to verify a claim. I understand

that any misrepresentation or omission of any material fact can result in denial of the claim.

Signature of Policyholder

Signature of Veterinarian

Date:

Print Veterinarian Name:

MM DD YY

Date:

MM DD YY

Please submit completed claims by:

CLINIC STAMP

Mail

Email

P.O. Box 2150

medicals@pethealthinc.com

Bu, NY 14240-2150

 

Fax

 

1.866.369.7387

 

Questions:

 

Call our Customer Care Unit at

 

1.877.707.7297

 

 

 

Applicable in Alaska

A person who knowingly and with intent to injure, defraud, or deceive an insurance company osecuted under state law.

Applicable in District of Columbia

WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or an insurer may deny insurance beneelated to a claim was provided by the applicant.

Applicable in Alabama, Arkansas, Louisiana, Maryland, Rhode Island, Texas, Utah and West Virginia

Any person who knowingly presents a false or fraudulent claim for payment of a loss or beneesents false information in an application for insurance is guilty of a crime and may be subject to con

Applicable in 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.

Applicable in Kentucky, Michigan, New Jersey, New Mexico and Pennsylvania.

Any person who knowingly and with intent to defraud any insurance company or another person, ading, information

concerning any fact, material thereto, commits a fraudulent insurance act, which is a crime, subject to criminal prosecution and civil penalties. In DC, LA, ME, TN and VA insurance bene denied.

Applicable in 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 payment of a loss is guilty of a crime and may be subject to con

Applicable in 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, 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 policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder 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 Regulator y Agencies.

Applicable in Delaware, Florida and Idaho

Any person who knowingly and with the intent to injure, Defraud, or Deceive any Insurance Company Files a Statement of Claim Containing any False, Incomplete or Misleading is Guilty of a Felony. * *In Florida – Third Degree Felony

Applicable in Hawaii

For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or bene

Applicable in Indiana

A person who knowingly and with intent to defraud an insurer .

Applicable in Minnesota

A person who er is guilty of a crime.

Applicable in Nevada

Pursuant to NRS 686A.291, any person who knowingly and willfully ning a material fact is guilty of a felony.

Applicable in New Hampshire

Any person who, with the purpose to injure, defraud or deceive any insurance company, osecution and punishment for insurance fraud, as provided in RSA 638:20.

Applicable in New York

Any person who knowingly and with intent to defraud any insurance company or other person ls 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 thousand dollars and the stated value of the claim for each such violation.

Applicable in Ohio

Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or insurance fraud.

Applicable in 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.

In the state of WA and all other states not mentioned above and Puerto Rico; it is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment,

Form Characteristics

Fact Name Description
Claim Submission Requirements The Shelter Care Claim form must be completed in full, necessitating attachment of a paid itemized invoice and the pet's medical history. Failure to include all necessary documentation will delay processing.
Veterinary Involvement Sections 2 and 3 of the form must be completed by the treating licensed veterinarian. This includes details about the diagnosis and treatment history, ensuring accurate claims processing.
Applicable State Laws In states such as Alabama, Kentucky, and New York, laws govern fraudulent claims. Misrepresentation can lead to criminal prosecution and denial of claims. Specific warnings are included for each state to inform policyholders of these risks.
Importance of Accurate Information Providing accurate and complete information is crucial for successful claims. Errors or missing details can not only delay processing but may also result in denial of the claim altogether.
Contact Information and Submission Methods The completed claim may be submitted via mail, email, or fax. Contact for assistance is provided, emphasizing the importance of direct communication for claim-related inquiries.

Guidelines on Utilizing Shelter Care Claim

Completing the Shelter Care Claim form involves gathering specific information and submitting relevant documents to ensure your claim is processed smoothly. Follow these steps carefully for accurate submission.

  1. Complete Section 1A with your pet’s information:
    • Policy Number
    • Pet Name
    • Species (Dog or Cat)
    • Breed
    • Age
  2. Fill out Section 1B with your details, including:
    • Your Name
    • Mailing Address
    • Email Address
    • Home and Cell Number
  3. Indicate any changes to your address or phone number in Section 1B.
  4. Have your treating veterinarian complete Sections 2 and 3 with required details about your claim.
  5. In Section 2, the veterinarian should clearly list each diagnosis and associated treatment dates, as well as note if the condition has been treated previously.
  6. Attach copy of your pet’s veterinary medical history, including detailed examination notes, lab reports, and any consultation notes.
  7. Sign the claim form in Section 3, confirming all information is accurate.
  8. Attach paid invoices that are detailed and itemized, showing costs and treatment performed.
  9. Submit the completed claim via mail, email, or fax as specified in the form.

Upon submission, the claim will be reviewed. Keep an eye on your email or contact the customer care unit for any inquiries regarding your claim status. This ensures you stay informed throughout the process.

What You Should Know About This Form

What is the purpose of the Shelter Care Claim form?

The Shelter Care Claim form is designed for pet owners to claim reimbursement for veterinary expenses related to their pet’s medical treatment. It requires detailed information about the pet, the policyholder, and the medical services provided to ensure accurate processing of the claim.

What documents must accompany the Shelter Care Claim form?

When submitting the claim form, include a paid itemized invoice and your pet’s complete medical history from both current and previous veterinary clinics. Missing documents and signatures can lead to delays in processing, so it's important to follow the checklist carefully.

How do I fill out the Shelter Care Claim form correctly?

Complete all required sections of the form. Ensure that your Policy Number and contact information are accurately noted. Additionally, have your veterinarian fill out Sections 2 and 3. Review the Terms and Conditions of your policy to confirm coverage for the specific medical condition being claimed.

What types of invoices are acceptable?

Invoices must be detailed and itemized. They should clearly indicate the cost of each treatment provided. Only paid invoices will be accepted unless a reimbursement agreement is established with the veterinarian. Avoid submitting account summaries, as they are not acceptable to process the claim.

What should be included in the veterinary medical records?

Medical records should include detailed examination or SOAP notes, lab/pathology/radiology reports, and any medical reports from referral or emergency hospitals. Transaction histories are not acceptable, and only comprehensive records will help expedite the claim process.

How can I submit my Shelter Care Claim form?

You can submit your completed claim form via several methods. Email the documents to medicals@pethealthinc.com, fax them to 1.866.369.7387, or mail them to P.O. Box 2150, Bu, NY 14240-2150. Ensure that all supporting documents are included to avoid delays.

Why is it important to review my Policy Documents?

Reviewing your Policy Documents is crucial to determine if coverage is available for the medical condition you are claiming. This helps you understand the scope of your coverage and ensures that the claim aligns with the terms of your policy.

What happens if I provide false information on the claim form?

Providing false or misleading information on the Shelter Care Claim form can result in claim denial and potential legal consequences. Most states have laws against insurance fraud, which can include imprisonment and civil penalties. It’s imperative to ensure that all information is factual and complete.

Can I submit multiple claims for my pet?

Only one claim form is allowed per pet for each specific medical condition being claimed. If multiple conditions were treated, separate forms for each condition must be submitted. This helps maintain clarity and ensures that each claim is processed accurately.

Common mistakes

When filling out the Shelter Care Claim form, several common mistakes can cause processing delays or even denial of the claim. Understanding these pitfalls can enhance the likelihood of a smooth and efficient claims process.

First, many individuals neglect to complete Section 1 thoroughly. This section requires not only the pet's information, such as name and breed, but also the policy number and the policyholder's contact information. Omitting any of these details can lead to confusion and significant delays in processing the claim. It's crucial to double-check that all sections are filled out before submission.

Second, failing to attach the appropriate veterinary records is another common error. The form clearly states that a complete veterinary medical history is necessary for processing the claim. This includes detailed examination notes and any lab or radiology reports. Invoices alone will not suffice. Without these records, the claim may be stalled as the insurer seeks additional documentation.

Third, many people overlook the importance of detailed invoices when submitting their claims. Invoices must be detailed and itemized, showing the costs associated with each treatment. A simple account summary does not meet this requirement and could result in denial. It's essential to review any submitted invoices to ensure they align with the required specifications.

Another frequent mistake involves the signatures in Section 3. Both the policyholder and the veterinarian need to sign the form. If either signature is missing, the claim may be rendered incomplete. It’s advisable to take a moment to verify that both required signatures are provided before sending off the paperwork.

Timing can also be a factor. Some claimants submit their form without checking the date. The form specifies that details about when the pet was registered and when treatments occurred are necessary. If these dates are not filled in accurately, it could lead to confusion about the timeline of care and treatment, potentially complicating the claims process.

Moreover, people often fail to verify their coverage before filing a claim. It’s vital to review the policy documents and terms and conditions to ensure the medical condition being claimed is covered. If a policyholder submits a claim for a condition that is not covered, it can be denied outright, wasting time and effort.

Lastly, it's essential to ensure that the veterinarian has completed Sections 2 and 3 properly. Sometimes, mistakes or omissions can occur on the veterinarian's part. Catching these errors before submission can save time and avoid complications. Collaboration with the veterinarian to ensure that all necessary information is accurate and complete will help streamline the claims process.

Documents used along the form

The Shelter Care Claim form is a vital document for submitting claims related to veterinary care for pets. Along with this form, several other documents and forms are commonly required to ensure a seamless claims process. Each of these documents plays a critical role in presenting a complete picture of the pet’s medical history and the associated costs. Below is a list of these documents with brief descriptions.

  • Paid Itemized Invoice: An invoice that details the medical services provided, including costs for each treatment. It must be marked as paid to qualify for reimbursement.
  • Medical History: Comprehensive records from current and past veterinary clinics, outlining the pet’s health and previous treatments.
  • Veterinary Examination Notes: Detailed notes from the veterinarian on the pet's examination, helping to clarify the diagnosis and treatment plan.
  • SOAP Notes: A structured method for documenting the pet's medical history, including Subjective, Objective, Assessment, and Plan information.
  • Lab Reports: Results from any laboratory tests performed, which provide crucial evidence about the pet's condition.
  • Radiology Reports: Imaging results (such as X-rays or ultrasounds) that support the diagnosis made by the veterinarian.
  • Referral Reports: Documentation from specialists or emergency clinics if the pet was referred for further treatment.
  • Transaction Histories: While not always accepted, these may occasionally provide context about previous treatments and payments made.
  • Account Summary: A broad overview of the pet's treatment costs; however, detailed invoices are typically required instead.
  • Claim Declaration: A signed statement affirming that the information provided in the claim is accurate and complete, protecting against potential fraud allegations.

Gathering these documents should be done carefully to avoid processing delays. Having complete and accurate information available can optimize the claims process and increase the chances of a successful reimbursement for veterinary costs incurred.

Similar forms

  • Claim for Reimbursement Form: Similar to the Shelter Care Claim form, this document requests detailed information about the incurred expenses and asks for itemized invoices. Both forms require signatures from relevant parties, ensuring that claims are valid and properly substantiated.
  • Health Insurance Claim Form: This form is often used in human health insurance. It similarly demands patient information, the medical provider's details, and itemized service descriptions. Both forms share the goal of verifying healthcare costs for consideration of coverage.
  • Pet Insurance Claim Form: Like the Shelter Care Claim form, this document collects information about the pet, treatment details, and associated costs. It also emphasizes the need for invoices and medical records to process claims effectively.
  • Accidental Injury Claim Form: This document requests information about the circumstances surrounding the injury, similar to how the Shelter Care Claim form requires diagnosis and treatment history. Both ensure that all necessary details accompany any claims made.
  • Workers’ Compensation Claim Form: Used in employment-related injuries, this form asks for detailed accounts of the injury and related costs, mirroring the Shelter Care Claim form's requirement for diagnostic information and invoices.
  • Medical Expense Claim Form: This form is used to claim expenses for medical services. It is similar in that it requires detailed information about treatments and supporting documentation to substantiate the claim, as seen with pet claims.

Dos and Don'ts

When filling out the Shelter Care Claim form, there are important dos and don'ts to consider to ensure a smooth process. Below is a list to guide you:

  • Do complete all sections of the form. Every part is essential for processing your claim.
  • Do include your pet’s medical history along with the claim form. This includes detailed veterinary records.
  • Do have the treating veterinarian fill out the necessary sections. Their insights are critical for the claim.
  • Do attach detailed and itemized paid invoices. This ensures that your claim reflects the actual costs incurred.
  • Do sign the Declarations Section to validate your claim submission before sending it in.
  • Don't submit more than one claim form per pet. This could confuse the processing team.
  • Don't forget to check for missing information. Any gaps can cause delays in claim processing.
  • Don't include general account summaries. Only specific, detailed invoices will be accepted.
  • Don't rely on oral explanations; provide written proof and documentation to support your claim.

Misconceptions

Misconceptions regarding the Shelter Care Claim form can lead to confusion and delays in processing claims. Here are ten common misconceptions clarified:

  1. Only one claim form is needed per pet. Many people think they can submit multiple forms for the same pet or condition. In fact, only one form is required for each pet's claim.
  2. Invoices from transaction histories are acceptable. In reality, detailed and itemized invoices specifically related to the treatment are required.
  3. A signature is optional on the claim form. This is false. The claim requires signatures from both the policyholder and the veterinarian for processing.
  4. Medical records can be vague. Providing detailed examination notes is mandatory. Incomplete records can cause delays.
  5. Submitting the claim form is enough. In addition to the form, attaching paid, itemized invoices and a complete medical history is necessary.
  6. The insurer covers all veterinary treatments automatically. Coverage depends on the policy documents. Review them to know which conditions are included.
  7. Claims can be processed without the veterinarian's involvement. The treating veterinarian must complete significant sections of the form before submission.
  8. There is no format required for invoices. Invoices must be clearly itemized, showing costs and referring to specific treatments for acceptance.
  9. Claims can be delayed only by missing documents. Inaccurate or unclear information can also lead to processing delays.
  10. Signatures do not need to match information provided. It's crucial that the signatures correspond with the names and details listed on the form to avoid discrepancies.

Understanding these misconceptions can streamline the claims process and help pet owners receive their due benefits promptly.

Key takeaways

When filling out the Shelter Care Claim form, there are several important points to keep in mind to ensure your claim is processed efficiently.

  • Complete All Sections: Ensure that every section of the form is filled out, as incomplete forms can lead to processing delays.
  • One Claim Form Per Pet: Each pet requires its own claim form. Do not submit multiple claims on a single form.
  • Attach Required Documents: Include a paid itemized invoice and the pet's medical history when submitting your claim.
  • Veterinarian's Role: Make sure the treating veterinarian completes Sections 2 and 3 of the form, as their input is crucial for the claim process.
  • Signatures Are Mandatory: The policyholder must sign the Declarations Section in Section 3. Without this signature, the claim cannot proceed.
  • Invoice Requirements: Ensure that invoices are detailed and itemized, listing all costs and treatments provided.
  • No Account Summaries: Only submit invoices; account summaries are not accepted for claims processing.
  • Past Treatments Matter: Clearly note if your pet’s medical condition has been treated previously, as this can impact your claim.
  • Include Medical Records: Attach detailed examination notes, lab reports, and medical reports for your claim to be effectively evaluated.
  • Double-Check for Accuracy: Review all entered information for accuracy. Any discrepancies may result in denial or delay of your claim.

Following these guidelines can help streamline the process and enhance the likelihood of a successful claim outcome.