INSTRUCTIONS: ALABAMA SOUTHLAND BENEFIT SOLUTIONS EMPLOYEE'S STATEMENT

Alabama state employees enrolled in medical coverage administered by Southland Benefit Solutions can use the form discussed in this article to file a claim for a hospital bill. This document can be obtained from the website maintained by Southland Benefit Solutions.

Alabama Southland Benefit Solutions Employee's Statement Step 1: Enter the subscriber's name in box 1.

Alabama Southland Benefit Solutions Employee's Statement Step 2: Enter the subscriber's contract number in box 2.

Alabama Southland Benefit Solutions Employee's Statement Step 3: Enter the subscriber's home address in box 3.

Alabama Southland Benefit Solutions Employee's Statement Step 4: Enter the patient's name in box 4.

Alabama Southland Benefit Solutions Employee's Statement Step 5: Enter the patient's date of birth in box 5.

Alabama Southland Benefit Solutions Employee's Statement Step 6: Enter the patient's age in box 6.

Alabama Southland Benefit Solutions Employee's Statement Step 7: Indicate the patient's sex with a check mark in box 7.

Alabama Southland Benefit Solutions Employee's Statement Step 8: Indicate the patient's relationship to the subscriber with a check mark in box 8.

Alabama Southland Benefit Solutions Employee's Statement Step 9: Enter the subscriber's home and work phone number in box 9.

Alabama Southland Benefit Solutions Employee's Statement Step 10: In box 10, enter the type of illness or injury or the doctor's diagnosis.

Alabama Southland Benefit Solutions Employee's Statement Step 11: In the next blank box, enter the physician's name and address.

Alabama Southland Benefit Solutions Employee's Statement Step 12: In the next blank box, enter the name of the hospital, if confined.

Alabama Southland Benefit Solutions Employee's Statement Step 13: In the next blank box, enter the date you were admitted.

Alabama Southland Benefit Solutions Employee's Statement Step 14: In the next blank box, enter the date you were discharged.

Alabama Southland Benefit Solutions Employee's Statement Step 15: In the next blank box, enter the date the accident or sickness began.

Alabama Southland Benefit Solutions Employee's Statement Step 16: In the next blank box, enter the date the accident or sickness was first treated.

Alabama Southland Benefit Solutions Employee's Statement Step 17: In the next blank box, indicate whether the condition was related to accident or illness.

Alabama Southland Benefit Solutions Employee's Statement Step 18: Sign and date the form where indicated.