Insured s Name: Policy Number: Claim Number: Caregiver s Name: (PLEASE PRINT) Tasks Performed. Location In2. Location Out2. Shift Charge.
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1 BST Invoice for Independent Health Care Providers Mail Address: Fax Number: Phone Number: Visit Us Online: Genworth Life & Annuity Insurance Company, Genworth Life Insurance Company, Genworth Life Insurance Company of New York Attn: LTCI Claims P.O. Box 40007, Lynchburg, VA Insured s Name: Policy Number: Claim Number: Caregiver s Name: (PLEASE PRINT) Tasks Performed Date Start1 End1 Hours Rate Total Hours: Total Charge: Miles Driven: Mileage Amount: Total Invoice Charge: Charge Location In2 Location Out2 BA DR TR CO TO EA AM CS HM (Key shown below) Tasks Key (Transportation for medically necessary, lifesustaining or safety functions in service to the Insured. The normal rate approved is the IRS medical rate ($0.19/mile). Please contact us for exceptions to this process.) BA DR TR CO TO EA AM CS HM (Bathing) (Dressing) (Transferring) (Continence) (Toileting) (Eating) (Ambulation) (Cognitive Supervision) (Homemaker Services) (Total Charge + Mileage Amount) Signature of Insured or Authorized Representative: Date: Signature of Caregiver: Date: ¹ Indicate AM or PM for Start and End ² Location In/Out refers to where the Caregiver is at the start and end of each shift (i.e., Insured s Home, Caregiver s Home, Doctor, etc.) (Rev 09/2016) Form Number Only Genworth Life Insurance Company of New York is admitted in and conducts business in New York.
2 ALABAMA FRAUD STATEMENT loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines and confinement in prison. ALASKA FRAUD STATEMENT Fraud Notice: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law. ARIZONA FRAUD STATEMENT Fraud Notice: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. ARKANSAS, LOUISIANA, RHODE ISLAND AND WEST VIRGINIA FRAUD STATEMENT loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. CALIFORNIA FRAUD STATEMENT Fraud Notice: For your protection, California law requires that you be made aware of the following: 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. COLORADO FRAUD STATEMENT Fraud Notice: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. DELAWARE FRAUD STATEMENT Fraud Notice: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony.
3 DISTRICT OF COLUMBIA FRAUD STATEMENT Fraud Notice: WARNING: It is a crime to provide false, or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the Applicant. FLORIDA FRAUD STATEMENT Fraud Notice: Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. HAWAII FRAUD STATEMENT Fraud Notice: For your protection, Hawaii law requires you to be informed that any person who presents a fraudulent claim for payment of a loss or benefit is guilty of a crime punishable by fines or imprisonment, or both. IDAHO FRAUD STATEMENT Fraud Notice: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. INDIANA FRAUD STATEMENT Fraud Notice: Any person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony. KENTUCKY FRAUD STATEMENT Fraud Notice: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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. MAINE FRAUD STATEMENT Fraud Notice: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. MARYLAND FRAUD STATEMENT loss or benefit or knowingly presents materially false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.
4 MINNESOTA FRAUD STATEMENT Fraud Notice: Any person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. NEW HAMPSHIRE FRAUD STATEMENT Fraud Notice: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20. NEW JERSEY FRAUD STATEMENT Fraud Notice: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. NEW MEXICO FRAUD STATEMENT loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. NEW YORK FRAUD STATEMENT Fraud Notice: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or 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. OHIO AND OREGON FRAUD STATEMENT Fraud Notice: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. OKLAHOMA FRAUD STATEMENT Fraud Notice: WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. PENNSYLVANIA FRAUD STATEMENT Fraud Notice: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or 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 subjects such person to criminal and civil penalties.
5 PUERTO RICO FRAUD STATEMENT Fraud Notice: Any person who knowingly and with the intent to defraud, presents Information in an insurance request form, or who presents, helps or has presented a fraudulent claim for the payment of a loss or other benefit, or presents more than one claim for the same damage or loss, will incur a felony, and upon conviction will be penalized for each violation with a fine no less than five thousand (5,000) dollars nor more than ten thousand (10,000) dollars, or imprisonment for a fixed term of three (3) years, or both penalties. If aggravated circumstances prevail, the fixed established imprisonment may be increased to a maximum of five (5) years; if attenuating circumstances prevail, it may be reduced to a minimum of two (2) years. TENNESSEE, VIRGINIA, AND WASHINGTON FRAUD STATEMENT Fraud Notice: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. CONNECTICUT, GEORGIA, ILLINOIS, IOWA, KANSAS, MASSACHUSETTS, MICHIGAN, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NORTH CAROLINA, NORTH DAKOTA, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WISCONSIN, AND WYOMING FRAUD STATEMENT loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.
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