Out of Network Claim Form Please fill out the information below and submit your claim, or click the button below to download and print the form to submit my mail. Download / Print Form
GVS will issue reimbursement checks to LOCAL 100 MEMBERS ONLY. No reimbursements will be issued for members who utilize in-network providers. ALL OUT OF NETWORK CLAIMS MUST BE SUBMITTED WITHIN 6 MONTHS FROM THE DATE OF SERVICE.
[gvs_form 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_name%22%2C%22prefilled%22%3A%22yes%22%2C%22prefill_with%22%3A%22current_day%22%7D%2C%7B%22input_type%22%3A%22file%22%2C%22input_values%22%3A%22%255B%257B%257D%255D%22%2C%22width%22%3A%22col-md-12%22%2C%22endpoint_field_name%22%3A%22attachment4_name%22%2C%22prefilled%22%3A%22yes%22%2C%22prefill_with%22%3A%22current_day%22%7D%2C%7B%22input_type%22%3A%22file%22%2C%22input_values%22%3A%22%255B%257B%257D%255D%22%2C%22width%22%3A%22col-md-12%22%2C%22endpoint_field_name%22%3A%22attachment5_name%22%2C%22prefilled%22%3A%22yes%22%2C%22prefill_with%22%3A%22current_day%22%7D%2C%7B%22title%22%3A%22%20%20All%20receipts%20must%20be%20submitted%20together%20at%20the%20same%20time%20even%20if%20services%20and%20materials%20were%20purchased%20on%20different%20dates.%22%2C%22input_type%22%3A%22message%22%2C%22input_values%22%3A%22%255B%257B%257D%255D%22%2C%22required%22%3A%22yes%22%2C%22width%22%3A%22col-md-12%22%2C%22prefill_with%22%3A%22current_day%22%7D%5D” endpoint=”oon_claim_gvs_app”][/gvs_form]