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Accident Questionnaire Form
- If your claim is the result of an accident, please complete this form to provide details about the accident and attach it to your claim.
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ACH & Wire Transfer Information Form
- If you need to provide or provide payment instructions for a direct transfer to your bank account, please attach this form to your claim.
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ASPE Claim Form
- If you have paid for a medical service out-of-pocket and need to file a claim for reimbursement to IMG you may complete this form. Please note! It is faster and easier to log in to your IMG ASPE account to submit a claim online. This .pdf form is not required if you submit a claim online.
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Privacy and Confidentiality Release Form
- If you need IMG to be able to discuss your medical services and claims activity with anyone other than you and your physician(s) or provider(s) of service (such as a parent, host family, spouse), you must complete and sign this form and send it to IMG.
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Release of Information Form
- If you need to authorize IMG to release your private health information (medical records) to a medical provider or another third-party (such as an other insurance company), please include this form with that request.
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