PAL CLAIMS UPDATED

1. Please make sure all questions on this page are answered completely. 2. Sign and date the authorization on page two (2 Please return a copy to us along with the completed claim form. You may want to retain a copyforyour records. 3. Please attach itemized hospital bills, physician bills and other documentation of expenses. Make sure all bills indicate a diagnosis code, procedure code, date of service and cost. Prescription receipts must furnish date, patient name, name of medication and name of prescribing physician. 4. Please retain a copy of your claim submission for your records.

Primary Insured's Name*

Primary Insured's Date of Birth*

Date

Daytime Telephone*

Email*

Policy #*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient's Full Name*

Patient's Date of Birth*

Date

Social Security Number

Relationship to Primary insured.*

PrimarySpouseChildOther

Nature of Claim*

PreventativeSicknessInjury

If Sickness, date Symptoms Started

Date

Date Injury Occurred

Date

Has this condition occurred before?*

YesNo

How and where did event occur?*

Brief description of condition requiring treatment?*

If accident or injury, please choose one of the following options*

Auto RelatedWork RelatedOther

Name of physician or medical facility *

Physician or medical facility address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is this condition covered by Worker's Compensation?*

YesNo

Is the patient covered by other insurance?*

YesNo

If yes, please provide name of insurance company*

Policies or Group number*

Are you filing for a dependent?*

YesNo

Is Dependent employed?*

YesNo

Is Dependent in school full-time?*

YesNo

If yes, please provide school or employer name and address

Expected graduation date

Date

Protected Health Information (PHI) to be Used and/or Disclosed: Any and all information or records relating to the medical history, medical examinations, services rendered, or treatment given, including treatment for alcohol abuse, substance abuse, mental or emotional disorders, A.I.D.S. (Acquired Immune Deficiency Syndrome), or A.R.C (AIDS-related complex). Entities or Persons

Authorized to Use or Disclose: U.S. Department of Health and Human Services (including the Centers for Medicare & Medicaid Services and any contractors or agents, including Medicare intermediaries), any physician or other health care professional, hospital or other health care facility, counselor, therapist or any other medical or medically related facility or professional. Entities or Persons Authorized to Receive: Philadelphia American Life Insurance Company (PALIC) or its agents, employees, designees, or representatives, including my PALIC agent or broker.

Purpose of this Authorization: By signing this form, you will authorize PALIC to use and/or disclose your Protected Health Information (PHI) to determine if your application will be approved for health insurance or that you are eligible for benefits. This authorization is a condition of your approved application for our health insurance or your eligibility for benefits. You also will authorize PALIC to obtain your Protected Health Information (PHI) from other covered entities so that we may determine payment of a claim for specified benefits involving you.

Effect of Declining: If you decide not to sign this authorization, we may decline to approve your application for health insurance or to provide benefits. This authorization may facilitate our consideration of a claim. If you decide not to sign this authorization, it may delay the processing of a claim. Effect of Granting this Authorization: The PHI to be used and/or disclosed may be subject to re-disclosure by the recipient, in which case it would no longer be protected under the HIPAA Privacy Rule.

Expiration: This authorization will expire upon the termination of any PALIC coverage that may be in effect.

Right to Revoke: I understand that I may revoke this authorization at any time by giving written notice of my revocation to: Philadelphia American Life Insurance Company, P.O. Box 4884, Houston, TX. 77210-4884 I understand that revocation of this authorization will not affect any action PALIC took in reliance on this authorization before PALIC received my written notice of revocation.

I have had full opportunity to read and consider the contents of this authorization, and I understand that, by signing this authorization, I am confirming my authorization of the use and/or disclosure of my Protected Health Information, as described in this authorization

A photocopy of this authorization is as valid as the original, and I and my PALIC agent or broker are entitled to receive a copy of this form. A COPY OF THIS AUTHORIZATION IS BEING PROVIDED TO YOU. YOU MAY ALSO REQUEST A COPY OF THE SIGNED AUTHORIZATION FROM US

I have had a full opportunity to read and consider the contents of this authorization. I understand that, by signing this form, I am confirming my authorization for the use and/or disclosure of my protected health information, as described in this form.

I Acknowledge

Agent Name:

Agent Phone#

Agent Email:

Name of Personal Representative

Relationship to insured patient.

Name of Personal Representative

Relationship to insured patient.

This authorization will expire on:

Date

On Occurrence of the following event:

Right To Revoke:You may revoke this authorization at any time by given a written notice to your MightyWELL Representative.

Primary Insured's Signature*

Date*

Date

MightyWELL Personalized Health Plan

Claim Form

Patient Information

Physician Information below

Secondary Insurance

Dependent information

Upload your Bill

Authorization to Obtain or Release Medical Information

Acknowledgements

Agent Information

Personal Representative

Expiration and Revocation

Authorized Signature