Davies Life & Health, Inc.

PO Box 7066 • Allentown PA 18105-7066

Phone: (877) 795-8493 • Fax: (877) 855-7817

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Monthly Verification of Continuing Care

Please complete this form for each month the Insured receives care. For your convenience, you may also upload/attach an itemized bill in electronic format while you are completing this form. If the itemized bill or invoice is not uploaded/attached with this form you will need to fax it separately to the fax number shown above. Any invoices submitted must be for the same dates of service as entered on this form. Please also note that this form should be completed for dates that have already occurred and not for future care/services.

Note: In order to receive prompt payment of available benefits, this form must be completed and submitted monthly by the Facility Administrator along with any additionally required documents.

Required fields look like this:

Insured Information[ prev | next ]

First:		Last:
Policy #:		DOB:
I acknowledge the following: FRAUD WARNING NOTICE: By signing this form and/or presenting information in connection with a claim, you acknowledge that you have received and read the state-specific Fraud Warnings document. For your protection, laws in CA and NY require the following to appear on this form. CA: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. NY: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, 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 five thousand dollars and the stated value of the claim for each such violation.

I acknowledge that I am the Facility Administrator from the facility providing care/services for the insured in which I am completing the information on this Monthly Verification of Continuing Care Form. I have read and understand the above Fraud Notice and agree to complete the information correctly and completely on this form.

Name of Facility:
Facility Email:
Address:
Phone #:
Fax #:

Initial Admission Date:
Discharge Date (if no longer confined):
Reason for Discharge (if applicable):
Duration of Service (please select one):	The Insured physically remained in the facility on every day of the month Insured was out of the facility on the following date(s)

Level of Care Provided This Month (select at least one)
	From	To		From	To
Nursing Care			Independent / No Care
Personal Care			Other Care

Monthly Verification of Continuing Care

Insured Information[ prev | next ]

Upload Invoice[ prev | next ]

Service Period[ prev | next | sign ]

Facility Information[ prev | next | sign ]

Dates of Service/Confinement[ prev | next | sign ]

Other Payer Source[ prev | next | sign ]

Signature[ prev | next | sign ]