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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 MyIMG account to Submit an Online Claim. This .pdf form is not required if you send an online claim.
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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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