Agent Guide | Home Health Care Select
Applications & Forms Application for Home Health Care Select Insurance
Completion instructions for the application included in this Agent Guide. Pages 1-7 must be completed in its entirety. A copy of the completed application will be made by ManhattanLife and attached to the policy to make it part of the contract. Often referred to as the “Prescription Drug Claim Form”. Used by a policyholder to make a claim against the policy for prescription drug benefits. Often referred to as the “Home Health Care Claim Form”. Used by a policyholder to make a claim against the policy for Home Health Care and home health care aide benefits. Often referred to as the “Physician Certification Claim Form”. Used by a physician to certify that a policyholder can no longer complete Activities of Daily Living and is eligible for Home Health Care and/or Home Health Care Aide services.
Prescription Drug Claim Form
HHC Standard Benefits Claim Form
Physician’s Home Health Certification
Submitting New Business Prior to submitting applications: • Review application for completeness and accuracy. • Verify correct premium amount. • Collect bank draft authorization information and signature(s) as applicable. • Any corrections must be initialed/dated by the applicant/owner. Do not use white-out.
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