Long-Term Care Insurance Claim Forms

Looking for long-term care insurance claim forms? Download commonly requested claim forms from leading long-term care insurance companies below. 

Request a free benefits review and we’ll help identify the paperwork needed to start your claim.   CareWorks helps seniors and families throughout Orange County understand their benefits, complete claim paperwork, and avoid common mistakes that can delay claim approval or reimbursement.

Request a Free Benefits Review Pencil Pencil

Not sure which forms you need? Before completing claim paperwork, verify your eligibility requirements, elimination period, and any required physician or RN assessment documentation. A quick benefits review can help prevent delays.

Insurance Company Claim Forms

Allianz Claim Form

Bankers Life Claim Initiation Forms

Bankers Life Long Term Care Form

Bankers Life Assignment of Benefits Form

Bankers Life HIPAA Release Form

The CalPERS Long-Term Care Program is administered by our third-party administrator, illumifin. Call Monday through Friday, 8:00 a.m. to 6:00 p.m. (Pacific Time) at (800) 982-1775.

CalPERs Agency Provider Form

CalPERs Agency Statement Calpers Appeal Form

CalPERs Assignment of Benefits Independent Provider

CalPERs Assignment of Benefits

CalPERs Assignment of Benefits Independent Provider

CalPERs Assignment of Benefits Service Provider

CalPERs Authorization to Release Individual Personal Representative Form

CalPERs Authorization Disclose Health

CalPERs How to File a Claim

CalPERs Independent Provider Packet

CalPERs Independent Provider Weekly Time Sheet

CalPERs Filing a Claim – What Is Needed?

CalPERs Online Claim Form

CalPERs PHI Form

CalPERs Reconsideration Form

CalPERs

CalPERs Form

CNA Authorization To Release Info Disclosure Form

CNA Claim Form

CNA Claimants Statement

CNA Assignment of Benefits AOB

CNA Third Party Authorization form

CNA-Alternate-Plan-of-Care-Request-Form

Conseco Claim Form

FedsLTC-Claims-Initiation-Kit

FedsLTC FLTCIP Claims-Initiation-Form

FedsLTC-FLTCIP_Authorization-Disclosure

FedsLTC Medical-Release

Feds LTC Home Care Agency Provider-Supplemental-Verification-Form

FedsLTC_Assignment-of-Benefits

Long Term Care Insurance Form

John Hancock Authorization Release Form

John Hancock Assignment of Benefits Form

Lincoln Financial Group Assignment Of Benefits

Lincoln Fnancial Group Care Provider Assessment

Lincoln Financial Group HIPAA

Lincoln Financial Group Insureds Statement Of Loss

Lincoln Financial Group POA

Metlife Guide To Service Provider Payment Home Care
Metlife Guide To Service Provider Payment Informal
Metlife Intake Packet Careworks As Future Provider
metlife_ltc
Metlife Privacy Authorization Release Group-IB

Mutual of Omaha Authorization for Disclosure Release of Info

Mutual of Omaha Application for Long Term Care Benefits

Mutual of Omaha Disability Form

Northwestern Mutual Claim Form

New York Life HIPAA

Penn Treaty Assignment of Benefits

Penn Treaty Attending Physicians Statement

Penn Treaty Facility Certification of Care For Initial Claim

Penn Treaty HIPAA

Penn Treaty Policyholder Authorizationto Release Information

Long-Term Patient Care Flow Sheet

Plan of Care / Treatment Plan

HIPAA Authorization

Assignment of Benefits

SHIP Assignment of Benefits Direction to Pay

SHIP Authorization Form

SHIP Claim Information Package

SHIP HIPAA Claims Processing

SHIP Senior Health Insurance Pennsylvania Claim Form

SHIP Claims Form

Thrivent Long Term Care

TransAmerica LTCI Claim

Long Term Care Claim Form

Medical Release Form

Consent for Release

UNUM Claim Form

Washington National Claim Form

Companies that prefer claims to be submitted online include:

Learn more about the long-term care insurance claims process and what happens after claim forms are submitted.

The California Department of Insurance Senior Resources Program offers educational information about insurance benefits and consumer protections.

Common Long-Term Care Insurance Claim Forms

Most long-term care insurance companies require some combination of the following forms and supporting documentation:

Claim Initiation Form

Used to officially open a long-term care insurance claim.

Physician Statement

Completed by a physician to document medical conditions, cognitive impairment, and the need for long-term care services.

Provider Statement

Completed by the home care agency to verify services provided.

Authorization to Release Information

Allows the insurance company to discuss claim information with approved family members or representatives.

Power of Attorney Documentation

Required when someone other than the policyholder is managing the claim.

Assignment of Benefits Form

Allows some insurance companies to pay the home care agency directly rather than reimbursing the policyholder.

Common Reasons Claim Forms Are Rejected or Delayed

Even when the correct forms are submitted, claims can be delayed because of:

  • Missing signatures
  • Incomplete physician statements
  • Missing provider information
  • Incomplete claim forms
  • Missing supporting documentation
  • Failure to submit required care plans
  • Missing Power of Attorney or authorization forms

Before submitting paperwork, it’s important to confirm which forms are required by your insurance company and whether additional documentation is needed.

Not Sure Which Forms You Need?

Different insurance companies require different paperwork. We can help identify the correct forms, verify benefits, explain policy requirements, and help you avoid common claim delays.

Complete the form below and we’ll help you understand your benefits, identify the required forms, and explain the next steps.

Request a Free Long-Term Care Insurance Benefits Review

Not sure what your policy covers or whether benefits are available? We'll review your policy and help you understand your options.

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Let us help you get your LTC insurance benefits

Still need help with filing a claim or finding home care in Huntington Beach, Laguna Woods, Laguna Hills, Seal Beach, Mission Viejo, or throughout Orange County? Reach out to us any time for assistance!