Healthcare Maternity Top Up Form

HEALTHCARE MATERNITY TOP UP FORM

Purpose: Use this form to request supplemental maternity top-up benefits in addition to any primary wage replacement or insurance benefits. Completion of this form authorizes the plan administrator and designated medical reviewers to verify the information provided. False statements may subject the applicant to recovery of payments and other remedies permitted by law.

Patient Information

Full legal name

Date of birth

Gender

Home address

Emergency contact (name & relationship)

Emergency contact phone

Employer / Plan Information

Employer or plan sponsor

Plan / policy name

Plan administrator (if different)

Insurance Information

Primary insurer

Subscriber name (if different)

Pregnancy & Leave Details

Expected due date:

Gestational age at first diagnosis (weeks):

Anticipated delivery method: Vaginal Cesarean Unknown

Expected number of weeks of leave (approximate):

Anticipated leave start date:

Requested Top-Up Benefit

I request supplemental top-up in the form of:

Weekly top-up amount

Total estimated top-up requested

Payment instructions / preferred payment method

Medical Provider Statement (To be completed by treating clinician)

Provider name and facility

Clinical diagnosis and comments

Provider attestation: By completing the clinical information above, the provider confirms the pregnancy-related facts reported are accurate to the best of their knowledge and that supporting records may be furnished upon request to the plan's authorized reviewers.

Authorization, Acknowledgment and Certifications

Authorization to obtain and disclose medical and employment information: I authorize any physician, medical facility, insurer, employer, or other person or entity who has records or knowledge of me or my employment to disclose such records and information to the plan administrator, third party administrator, and their authorized agents for the purpose of evaluating and administering this maternity top-up request. This authorization includes, but is not limited to, medical records relating to pregnancy, delivery, and related conditions as well as employment and payroll records necessary to determine benefit entitlement and amount.

Use and duration of authorization: This authorization is valid through the date selected below or for twelve (12) months from the date of my signature if no expiration date is provided. I understand I may revoke this authorization at any time in writing, except to the extent that action has already been taken in reliance on it.

Recovery and repayment: I understand and agree that any top-up payments made in error or in excess of the amount for which I am eligible may be recovered from future payments to me, or I may be required to reimburse the plan or employer for overpayments. I further understand that top-up benefits may cease upon my return to work or termination of eligibility under the governing plan document.

Certification of accuracy: I certify under penalty of law that the information I have provided on this form is true, complete, and correct to the best of my knowledge. I understand that intentional misrepresentation may result in denial of benefits and may be subject to civil or criminal penalties.

Authorization expiration date (optional)

HIPAA acknowledgment: I acknowledge that health information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations. I understand the purpose of the disclosure and that I may request a copy of this authorization.

By checking this box I acknowledge receipt of and consent to the HIPAA-related statement above.

Additional Declarations

I consent to communications regarding this request by telephone, email, or mail to the contact information provided. I understand that approval of top-up benefits is subject to the terms and conditions of the governing plan, and this form does not guarantee payment.

I agree to notify the plan administrator promptly of any changes in my employment status, expected delivery date, or medical condition that may affect my eligibility or the amount of top-up benefits payable.

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