forms

Medical Claim Form

For reimbursement, complete items
1-9 of the claim form,
attach receipt(s) and submit to:


Tri-County Schools Insurance Group

c/o Delta Health Systems

P. O. Box 80

Stockton, CA 95201-3080

 

If you need Delta Health Systems to reimburse the provider,
then also sign item 10 and following the same procedures
listed above.

 

One claim form per patient.

 

Third Party Liability Form (TPL)

Coordination of Benefits Form (COB)

JPA Delegate Forms

Designation of Delegate

Form 700

 

1176 LIVE OAK BOULEVARD, SUITE A | YUBA CITY, CA 95991 | 866-822-5299

© TRI-COUNTY SCHOOLS INSURANCE GROUP