<h4><strong>Claims Support Forms</strong></h4>
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<td colspan="2" rowspan="1" width="100%" style="padding: 0.75pt; width: 962.328px; height: 15pt;"><p style="margin: 6pt 0.1in;">{fontweight=500:Claims Forms}<br> These forms are for providers to use to submit their TOP Claims to the TOP Claims Processor.</p></td>
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<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.156px; height: 15pt;"><p style="margin: 6pt 0.1in;">Claim Development Worksheet</p></td>
<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.172px; height: 15pt;"><p style="margin: 6pt 0.1in;">{ downloaddocs=/providers/tco-media/documents/CDW-FINAL-MAY2024-ARABIC:Arabic} | {downloaddocs=/providers/tco-media/documents/CDW-MAR2025-ENG:English} | {downloaddocs=/providers/tco-media/documents/CDW-FINAL-MAY2024-FRENCH:French } | {downloaddocs=/providers/tco-media/documents/CDW-FINAL-MAY2024-GERMAN:German } | {downloaddocs=/providers/tco-media/documents/CDW-FINAL-MAY2024-Greek:Greek } | {downloaddocs=/providers/tco-media/documents/CDW-FINAL-MAY2024-Italian:Italian } | {downloaddocs=/providers/tco-media/documents/CDW-FINAL-JAPANESE-MAY-2024:Japanese} | {downloaddocs=/providers/tco-media/documents/CDW-FINAL-MAY2024-Korean:Korean } | {downloaddocs=/providers/tco-media/documents/CDW-FINAL-MAY2024-Polish:Polish } | {downloaddocs=/providers/tco-media/documents/CDW-FINAL-MAY2024-Portuguese:Portuguese } | {downloaddocs=/providers/tco-media/documents/CDW-FINAL-MAY2024-SPANISH:Spanish } | {downloaddocs=/providers/tco-media/documents/CDW-FINAL-MAY2024-TURKISH:Turkish }</p></td>
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<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.156px; height: 15pt;"><p style="margin: 6pt 0.1in;">CMS 1500 Claim Form</p></td>
<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.172px; height: 15pt;"><p style="margin: 6pt 0.1in;">{downloaddocs=/providers/tco-media/documents/CMS1500_ver02-12:English}</p></td>
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<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.156px; height: 15pt;"><p style="margin: 6pt 0.1in;">UB-04 Claim Form</p></td>
<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.172px; height: 15pt;"><p style="margin: 6pt 0.1in;">{downloaddocs=/providers/tco-media/documents/UB-04Form:English}</p></td>
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<td colspan="2" rowspan="1" width="100%" style="padding: 0.75pt; width: 962.328px; height: 15pt;"><p style="margin: 6pt 0.1in;">{fontweight=500:Medical Care Pre-Approval Forms}<br> Providers can use these pre-approval forms when applicable for specific conditions or medical care that require pre-approval.</p></td>
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<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.156px; height: 15pt;"><p style="margin: 6pt 0.1in;">Obesity Management with Weight-Loss Medications Pre-Approval Form</p></td>
<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.172px; height: 15pt;"><p style="margin: 6pt 0.1in;">{downloaddocs=/providers/tco-media/documents/Pre-Approval-Weight-Loss-Medication-Form-English:English} | {downloaddocs=/providers/tco-media/documents/Pre-Approval-Weight-Loss-Medication-Form-German:German} | {downloaddocs=/providers/tco-media/documents/Pre-Approval-Weight-Loss-Medication-Form-Italian:Italian} | {downloaddocs=/providers/tco-media/documents/Pre-Approval-Weight-Loss-Medication-Form-March2026-JAP:Japanese} | {downloaddocs=/providers/tco-media/documents/Pre-Approval-Weight-Loss-Medication-Form-Korean:Korean} | {downloaddocs=/providers/tco-media/documents/Pre-Approval-Weight-Loss-Medication-Form-Spanish:Spanish} | {downloaddocs=/providers/tco-media/documents/Pre-Approval-Weight-Loss-Medication-Form-Polish:Polish}</p></td>
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<td colspan="2" rowspan="1" width="100%" style="padding: 0.75pt; width: 962.328px; height: 15pt;"><p style="margin: 6pt 0.1in;">{fontweight=500:Signature on File Forms}<br> These forms are for providers to capture beneficiary signature/consent to submit claims on their behalf and release medical records to International SOS.</p></td>
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<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.156px; height: 15pt;"><p style="margin: 6pt 0.1in;">Beneficiary Signature on File</p></td>
<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.172px; height: 15pt;"><p style="margin: 6pt 0.1in;">{downloaddocs=/providers/tco-media/documents/Beneficiary-SOF-JUNE2026-English:English} | {downloaddocs=/providers/tco-media/documents/Beneficiary-SOF-AUG2026-French:French} | {downloaddocs=/providers/tco-media/documents/beneficiary-sof-final-may-2018-japanese:Japanese}</p></td>
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<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.156px; height: 15pt;"><p style="margin: 6pt 0.1in;">Patient Administrative Form (PAF)</p></td>
<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.172px; height: 15pt;"><p style="margin: 6pt 0.1in;">{downloaddocs=/providers/tco-media/documents/PAF-FEB2025-ENG:English} | {downloaddocs=/providers/tco-media/documents/PAF-FEB2025-FRE:French} | {downloaddocs=/providers/tco-media/documents/PAF-FEB2025-GER:German} | {downloaddocs=/providers/tco-media/documents/PAF-FEB2025-ITA:Italian} | {downloaddocs=/providers/tco-media/documents/patient-administration-form-japanese-paf-jan-2020:Japanese} | {downloaddocs=/providers/tco-media/documents/patient-administration-form-korean-paf-jan-2020:Korean} | {downloaddocs=/providers/tco-media/documents/PAF-FEB2025-POL:Polish} | {downloaddocs=/providers/tco-media/documents/PAF-FEB2025-POR:Portuguese} | {downloaddocs=/providers/tco-media/documents/PAF-FEB2025-SPA:Spanish} | {downloaddocs=/providers/tco-media/documents/PAF-FEB2025-TUR:Turkish}</p></td>
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<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.156px; height: 15pt;"><p style="margin: 6pt 0.1in;">Provider Signature on File</p></td>
<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.172px; height: 15pt;"><p style="margin: 6pt 0.1in;">{downloaddocs=/providers/tco-media/documents/Provider-SOF-JAN2025-ENGLISH:English} | {downloaddocs=/providers/tco-media/documents/Provider-SOF-JAN2025-ARABIC:Arabic} | {downloaddocs=/providers/tco-media/documents/Provider-SOF-MAR2025-FRENCH:French} | {downloaddocs=/providers/tco-media/documents/Provider-SOF-JAN2025-GERMAN:German} | {downloaddocs=/providers/tco-media/documents/Provider-SOF-JAN2025-ITALIAN:Italian} | {downloaddocs=/providers/tco-media/documents/Provider-SOF-JAN2025-JAPANESE:Japanese} | {downloaddocs=/providers/tco-media/documents/Provider-SOF-JAN2025-KOREAN:Korean} | {downloaddocs=/providers/tco-media/documents/Provider-SOF-JAN2025-POLISH:Polish} | {downloaddocs=/providers/tco-media/documents/Provider-SOF-JAN2025-PORTUGUESE:Portuguese} | {downloaddocs=/providers/tco-media/documents/Provider-SOF-JAN2025-SPANISH:Spanish} | {downloaddocs=/providers/tco-media/documents/Provider-SOF-JAN2025-TURKISH:Turkish}</p></td>
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<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.156px; height: 15pt;"><p style="margin: 6pt 0.1in;">Beneficiary Consent to Release of Medical Information Form (ROMIF)</p></td>
<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.172px; height: 15pt;"><p style="margin: 6pt 0.1in;">{downloaddocs=/providers/tco-media/documents/ROMIF-JUNE2026-English:English} | {downloaddocs=/providers/tco-media/documents/ROMIF-AUG2026-French:French}</p></td>
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<td colspan="2" rowspan="1" width="100%" style="padding: 0.75pt; width: 962.328px; height: 15pt;"><p style="margin: 6pt 0.1in;">{fontweight=500:Electronic Payment Forms}<br> These forms are for providers to get paid electronically for TOP Claims.</p></td>
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<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.156px; height: 15pt;"><p style="margin: 6pt 0.1in;">Electronic Fund Transfer (EFT) Form</p></td>
<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.172px; height: 15pt;"><p style="margin: 6pt 0.1in;">{downloaddocs=/providers/tco-media/documents/EFT-Form-English-FEB2022:English} | {downloaddocs=/providers/tco-media/documents/EFT-Form-French-FEB2022:French} | {downloaddocs=/providers/tco-media/documents/EFT-Form-German-FEB2022:German} | {downloaddocs=/providers/tco-media/documents/EFT-Form-Greek-FEB2022:Greek} | {downloaddocs=/providers/tco-media/documents/EFT-Form-Providers-FINAL-Feb-2022-HUNGARIAN:Hungarian} | {downloaddocs=/providers/tco-media/documents/EFT-Form-Italian-FEB2022:Italian} | {downloaddocs=/providers/tco-media/documents/EFT-Form-Portuguese-FEB2022:Portuguese} | {downloaddocs=/providers/tco-media/documents/EFT-Form-Spanish-FEB2022:Spanish} | {downloaddocs=/providers/tco-media/documents/EFT-Form-Turkish-FEB2022:Turkish}</p></td>
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<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.156px; height: 15pt;"><p style="margin: 6pt 0.1in;">Electronic Fund Transfer (EFT) for Providers using a Billing Agency</p></td>
<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.172px; height: 15pt;"><p style="margin: 6pt 0.1in;">{downloaddocs=/providers/tco-media/documents/EFT-Form-BA-English-FEB2022:English} | {downloaddocs=/providers/tco-media/documents/EFT-Form-BA-French-FEB2022:French} | {downloaddocs=/providers/tco-media/documents/EFT-Form-BA-German-FEB2022:German} | {downloaddocs=/providers/tco-media/documents/EFT-Form-BA-Greek-FEB2022:Greek} | {downloaddocs=/providers/tco-media/documents/EFT-Form-Providers-with-Billing-Agency-HUNGARIAN:Hungarian} | {downloaddocs=/providers/tco-media/documents/EFT-Form-BA-Italian-FEB2022:Italian} | {downloaddocs=/providers/tco-media/documents/EFT-Form-BA-Portuguese-FEB2022:Portuguese} | {downloaddocs=/providers/tco-media/documents/EFT-Form-BA-Spanish-FEB2022:Spanish} | {downloaddocs=/providers/tco-media/documents/EFT-Form-BA-Turkish-FEB2022:Turkish}</p></td>
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<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.156px; height: 15pt;"><p style="margin: 6pt 0.1in;">Automated Clearing House (ACH) and Wire Payment Form</p></td>
<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.172px; height: 15pt;"><p style="margin: 6pt 0.1in;">{downloaddocs=/providers/tco-media/documents/ACH-WPF-FEB2022:English}</p></td>
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<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.156px; height: 15pt;"><p style="margin: 6pt 0.1in;">W9 Form – This form should be sent together with the ACH and Wire Payment Form</p></td>
<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.172px; height: 15pt;"><p style="margin: 6pt 0.1in;">{downloaddocs=/providers/tco-media/documents/W9-Form-FEB2022:English}</p></td>
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<td colspan="2" rowspan="1" width="100%" style="padding: 0.75pt; width: 962.328px; height: 15pt;"><p style="margin: 6pt 0.1in;">{fontweight=500:Secure Claims Portal Forms}<br> These forms are for providers to benefit from all the key functions of the Secure Claims Portal, including registering for online claims submission and receiving your remittance advice via email. For EDI registration requirements, please {downloaddocs=/providers/tco-media/documents/EDI-Express-Enrollment-E3-User-Guide:click here}.</p></td>
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<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.156px; height: 15pt;"><p style="margin: 6pt 0.1in;">Electronic Data Interchange (EDI) Enrollment Form: Online Claims Submission Registration <i>*Not to be used in U.S. Territories</i></p></td>
<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.172px; height: 15pt;"><p style="margin: 6pt 0.1in;">{downloaddocs=/providers/tco-media/documents/EDI-Enrollment-Form-ENG-JAN2026:English} | {downloaddocs=/providers/tco-media/documents/EDI-Enrollment-Form-Arabic-JAN2026:Arabic} | {downloaddocs=/providers/tco-media/documents/EDI-Enrollment-Form-French-JAN2026:French} | {downloaddocs=/providers/tco-media/documents/EDI-Enrollment-Form-German-JAN2026:German} | {downloaddocs=/providers/tco-media/documents/EDI-Enrollment-Form-Greek-JAN2026:Greek} | {downloaddocs=/providers/tco-media/documents/EDI-Enrollment-Form-Hungarian-JAN2026:Hungarian} | {downloaddocs=/providers/tco-media/documents/EDI-Enrollment-Form-Italian-JAN2026:Italian} | {downloaddocs=/providers/tco-media/documents/EDI-Enrollment-Form-Japanese-JAN2026:Japanese} | {downloaddocs=/providers/tco-media/documents/EDI-Enrollment-Form-Korean-JAN2026:Korean} | {downloaddocs=/providers/tco-media/documents/EDI-Enrollment-Form-Polish-JAN2026:Polish} | {downloaddocs=/providers/tco-media/documents/EDI-Enrollment-Form-Portuguese-JAN2026:Portuguese} | {downloaddocs=/providers/tco-media/documents/EDI-Enrollment-Form-Romanian-JAN2026:Romanian} | {downloaddocs=/providers/tco-media/documents/EDI-Enrollment-Form-Spanish-JAN2026:Spanish} | {downloaddocs=/providers/tco-media/documents/EDI-Enrollment-Form-Turkish-JAN2026:Turkish}</p></td>
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<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.156px; height: 15pt;"><p style="margin: 6pt 0.1in;">Electronic Data Interchange (EDI) Enrollment for Online Claims Submission Registration for U.S. Territories ONLY</p></td>
<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.172px; height: 15pt;"><p style="margin: 6pt 0.1in;"><a href="https://urldefense.com/v3/__https:/www.wpshealth.com/resources/provider-resources/edi/enrollment.shtml__;!!LMhewFfBWZ5W!IqVzNBN-yA_bLqwbR-EbiCr0Wdh5Ta59bsh71ZZFotzhu5xiVK3tpC_5u-WKB-2QWw2Zo3Xj-IoSxMdCDxAM_SErUA$" style="color: rgb(4, 105, 193); text-decoration: underline;" target="_blank">https://www.wpshealth.com/resources/provider-resources/edi/enrollment.shtml</a></p></td>
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<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.156px; height: 15pt;"><p style="margin: 6pt 0.1in;">Electronic Remittance Advice (ERA) Authorization & Instructions Form: Remittance Advice Email</p></td>
<td colspan="1" rowspan="1" width="50%" style="padding: 0.75pt; width: 481.172px; height: 15pt;"><p style="margin: 6pt 0.1in;">{downloaddocs=/providers/tco-media/documents/ERA-Form-OCT2021:English} | {downloaddocs=/providers/tco-media/documents/ERA-Form-Oct2021-German:German} | {downloaddocs=/providers/tco-media/documents/ERA-Form-Oct2021-Spanish:Spanish} | {downloaddocs=/providers/tco-media/documents/ERA-Form-Oct2021-Italian:Italian} | {downloaddocs=/providers/tco-media/documents/ERA-Form-Oct2021-French:French} | {downloaddocs=/providers/tco-media/documents/ERA-Form-Oct2021-Portuguese:Portuguese} | {downloaddocs=/providers/tco-media/documents/ERA-Form-Oct2021-Greek:Greek} | {downloaddocs=/providers/tco-media/documents/ERA-Form-Oct2021-Turkish:Turkish} | {downloaddocs=/providers/tco-media/documents/ERA-Form-Oct2021-Polish:Polish}</p></td>
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</table>
<h4><br></h4>