Filling Group Short-Term Disability Claim Form Guide
This guide provides detailed instructions for completing the Group Short-Term Disability Claim Form provided by Mutual of Omaha. It includes information on how to fill out each section of the form and important fraud warnings. This document is essential for employees who need to apply for short-term disability benefits.
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How do I fill this out?
To begin filling out the Group Short-Term Disability Claim Form, start by providing accurate and complete information in all sections. Ensure that you answer all questions and sign the form where required. Detailed instructions for each section are provided on the following pages.
How to fill out the Filling Group Short-Term Disability Claim Form Guide?
1
Start with the Employee Statement section and provide all required personal and employment information.
2
Fill out the Authorization to Disclose Personal and Health Information section and sign it.
3
Have your employer complete the Employer's Statement section.
4
Request your physician to fill out and sign the Attending Physician's Statement section.
5
Review the completed form, make a copy for your records, and submit it to Mutual of Omaha using the provided contact details.
Who needs the Filling Group Short-Term Disability Claim Form Guide?
1
Employees who need to apply for short-term disability benefits.
2
Employers who need to provide information about an employee's disability claim.
3
Physicians who need to provide medical information and certification for an employee's disability claim.
4
Benefits administrators who assist employees in completing and submitting disability claims.
5
HR professionals who manage employee benefits and disability claims.
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What are the instructions for submitting this form?
To submit the completed Group Short-Term Disability Claim Form, you can email it to newdisabilityclaim@mutualofomaha.com. Alternatively, you can fax the form to (402) 997-1865, or mail it to the following address: Group Insurance Claims Management, Mutual of Omaha, 3300 Mutual of Omaha Plaza, Omaha, NE 68175-0001. Make sure to keep a copy for your records and verify all sections are completed accurately before submission. For any questions or assistance, contact Mutual of Omaha at (800) 877-5176.
What is the purpose of this form?
The purpose of the Group Short-Term Disability Claim Form is to provide essential information for determining eligibility for short-term disability benefits. This form collects detailed personal, employment, and medical information from the employee, employer, and attending physician. Accurate completion of this form ensures timely processing and determination of disability benefits.
Tell me about this form and its components and fields line-by-line.
- 1. Employee Statement: Includes personal details, job information, and dates related to the disability.
- 2. Authorization to Disclose Personal Information: Employee's consent for sharing personal information with necessary parties.
- 3. Authorization to Disclose Health Information: Employee's consent for sharing health information with the employer.
- 4. Employer's Statement: Details provided by the employer about the employee's job and coverage.
- 5. Attending Physician's Statement: Medical information and certification provided by the attending physician.
What happens if I fail to submit this form?
Failure to submit the form may result in delays or denial of short-term disability benefits. Ensure all sections are completed and the form is submitted on time.
- Denial of Benefits: Incomplete or late submission may lead to the denial of disability benefits.
- Processing Delays: Missing information or signatures can cause delays in processing the claim.
- Incomplete Documentation: Failure to provide all required documentation may result in the need for additional submissions.
How do I know when to use this form?
- 1. Disability Benefits: Apply for short-term disability benefits due to illness or injury.
- 2. Personal Information Authorization: Authorize the disclosure of personal information for claim processing.
- 3. Medical Information Authorization: Authorize the disclosure of health information to the employer.
- 4. Employer's Input: Provide the employer's statement on the employee's job and coverage details.
- 5. Physician's Certification: Include medical information and certification from the attending physician.
Frequently Asked Question
How do I fill out the Group Short-Term Disability Claim Form?
Follow the detailed instructions provided in the guide and use PrintFriendly's PDF editor to complete all required sections accurately.
Can I sign the form electronically?
Yes, PrintFriendly allows you to electronically sign the PDF form using our built-in signing tool.
How do I submit the completed form?
Submit the form by emailing, faxing, or mailing it to the provided contact details of Mutual of Omaha.
Can I make edits to the form after filling it out?
Yes, you can use PrintFriendly's PDF editor to make any necessary edits before finalizing the document.
Is it possible to share the completed form with others?
Absolutely, PrintFriendly provides sharing options to email or generate a shareable link for the completed form.
What information do I need to provide in the Employee Statement section?
You need to provide personal and employment information, including your job title, hours worked, and date of disability.
Who needs to complete the Employer's Statement section?
The Employer's Statement section must be completed and signed by your employer.
What should be included in the Attending Physician's Statement section?
Your physician needs to provide medical information, treatment details, and certify your disability.
Are there any fraud warnings associated with this form?
Yes, there are specific fraud warnings provided for different states that must be read before completing the form.
Can I save a copy of the completed form for my records?
Yes, it is recommended to make a copy of the completed form for your records before submitting it.
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