Return your completed forms to:

Long Term Care Partners, LLC
P.O. Box 797
Greenland, NH 03840-0797

Email: claimsinfo@ltcpartners.com

Fax: 1-866-513-2674

Need more help? Get answers to frequently asked questions about claims.

 

Claims Forms

Claims Forms

For enrollees who are beginning the claims process

To file a claim, there are three required forms that must be completed and returned to us before we can determine if you're eligible for benefits. The fourth form is optional. Click on the description links below to learn more about each form.

Brochure Download
Beginning the Claims Process [Description] icon to download the Adobe Acrobat PDF version.
Required Forms Download
Care Support History [Description] icon to download the Adobe Acrobat PDF version.
Medical Release [Description] icon to download the Adobe Acrobat PDF version.
IRS Form W-9 [Description] icon to download the Adobe Acrobat PDF version.
Optional Form Download
Authorization for Disclosure of Information [Description] icon to download the Adobe Acrobat PDF version.

If a legal representative is authorized to make decisions on your behalf about your long term care insurance policy, we require a legal copy of your durable financial power of attorney or guardianship papers (as determined by your state of residence). We will not be able to proceed with the claim until we've received this documentation. Note: A health care proxy is not sufficient for this purpose.

 

For enrollees who are already claimants

Below are important forms and instructions to assist you in the reimbursement of approved care expenses.

Brochures Download
Using Your FLTCIP Benefits: FLTCIP 1.0 [Description] icon to download the Adobe Acrobat PDF version.
Using Your FLTCIP Benefits: FLTCIP 2.0 [Description] icon to download the Adobe Acrobat PDF version.
Forms Download
Informal Caregiver Invoice [Description] icon to download the Adobe Acrobat PDF version.
Assignment of Benefits Form [Description] icon to download the Adobe Acrobat PDF version.
Claimant Authorization of Claims Payments via Electronic Funds Transfer [Description] icon to download the Adobe Acrobat PDF version.
Provider Authorization of Claims Payments via Electronic Funds Transfer [Description] icon to download the Adobe Acrobat PDF version.