Employer Termination/Deletion Form		Credit Card Authorization
	Atlantis Rewards Program Application

Instructions When Completing Atlantis Heath Plan Claim Form

1. Complete Sections 1-13 to the best of your ability
2. Complete new form for each member of the family that you are submitting medical expenses
3. New forms must be used on subsequent submissions
4. Photo-copy or faxes are not acceptable
5. Mail claims to address listed on upper right corner of HCFA 1500 form
6. Adherence to these guidelines will enable us to process your claims in at timely manner.

Health Insurance Claim Form (HCFA 1500)

If you have any questions contact our Member Services Department at 1-866-747-8422. Member claims should be mailed to 39 Broadway, Suite 1240, New York, NY 10006.