Pet Insurance form

By submitting this form, you certify that the information provided to McGehee Clinic for Animals is truthful, accurate, and complete. I understand that deliberate misrepresentation of my pet’s condition or the omission of any material facts may result in the denial of a claim and/or the cancellation of the insurance. I authorize Heart of Chelsea Veterinary Group to provide to the insurer any details it may require to complete this claim, including but not limited to, all medical records, including those from outside facilities. While we provide our best service to assist you with your insurance needs, McGehee Clinic for Animals will not be held liable for the outcome or denial of any claims. *

McGehee Clinic for Animals cannot retroactively submit claims more than 90 days past the date of service. *

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. *