Texas PDF Templates

Texas PDF Templates
Homepage ➾ Blank Texas Legal Claim PDF Template
Contents

Form Example

PART 1 PARTICIPANT INFORMATION

Member Name:

Subscriber ID:

Group ID:

Mailing Address:

Mailing City, ST, Zip:

,

 

 

Email Address:

 

 

 

Home/Cell Phone No.:

 

 

 

Office Phone No.:

 

 

 

PART 2 CLIENT INFORMATION (if not listed above)

Name:

Date of Birth:

Relationship to Member:

Contact Phone No.:

By checking this box I certify that the client/dependent (excepting spouse of Member) was under the age of 25 at the time when the legal matter occurred.

CLAIM FORM

PART 3 COVERAGE VERIFICATION

Contact TLPP for eligibility verification prior to providing service(s)

Toll (800) 252-9346 | Austin (512) 327-1372 | Email eligibility@tlpp.org

Date:

Authorization No.:

Notes:

OBTAINING VERIFICATION IS NOT A GUARANTEE OF PAYMENT

PART 4 ATTORNEY INFORMATION

Attorney Name:

Attorney TLPP ID:

Billing Address

Billing City, ST, Zip: ,

Email Address:

Telephone No.:

Fax No.:

Updated contact information provided

PART 5 SERVICES PERFORMED (refer to TLPP Participating Attorney Fee Schedule for codes and descriptions)

First Date of Service

Final Date of Service

Code

Description

Qty/Hour(s)

Charge

TOTALS

PART 6 COURT RELATED INFORMATION

Court/Administrative/Charge Date:

First Filing Date:

Court/Agency Name:

Cause/Docket No.:

PART 8 CLAIM SUBMISSION

Fax (512) 327-0163 | Email claims@tlpp.org

Mailing 7500 Rialto Blvd, Bldg One, Ste 120, Austin, Texas 78735

NOTICE By submitting this claim you are affirming that the legal matter has been finalized. Be advised that TLPP does not make interim payments.

PART 7 AUTHORIZATING SIGNATURES

MEMBER OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any legal or other information necessary to process this claim. I also request payment of benefits either to myself or to the party who accepts TLPP.

Participating Member Signature

Date

I certify that the service(s) listed were necessary for the legal services of the client and were personally furnished by me or my employee(s) under my personal direction. I certify that the foregoing information is true, accurate and complete. The itemized statement submitted includes hourly billing. I agree not to bill the Member and/or the Client for any covered legal services.

Participating Attorney Signature

Date

PART 9 TLPP Office Use Only

Effective Date:

Process Date:

Received Date:

Payment:

 

 

 

 

Coverage Type:

Batch No.:

Claim Count:

Claim No.:

 

 

 

 

Toll (800) 252-9346 | Fax (512) 327-0163 | Austin (512) 327-1372 | Office 7500 Rialto Boulevard, Building One, Suite 120, Austin, Texas 78735 |

Web www.tlpp.org

CREATED AND ENDORSED BY THE STATE BAR OF TEXAS SINCE 1972

12/2011

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Common mistakes

  1. Incomplete Participant Information: Failing to fill out all required fields in the participant section can lead to delays. Ensure that the member's name, subscriber ID, and contact information are fully provided.

  2. Neglecting Client Information: If the claim involves a client or dependent, omitting their details can cause complications. Always include the client’s name, date of birth, and relationship to the member.

  3. Ignoring Coverage Verification: Not verifying eligibility before providing services can result in unexpected costs. Always contact TLPP to confirm coverage prior to service delivery.

  4. Errors in Attorney Information: Incorrect or missing attorney details, such as the attorney’s name or TLPP ID, can hinder the processing of your claim. Double-check this information for accuracy.

  5. Incorrect Service Details: Failing to accurately list the dates of service, codes, and charges can lead to claim denials. Be sure to refer to the TLPP Participating Attorney Fee Schedule for correct codes.

  6. Omitting Court Related Information: Not providing details about the court or agency involved can slow down your claim. Include the court name, cause number, and relevant dates.

  7. Missing Authorizing Signatures: Forgetting to sign the claim form can result in rejection. Ensure that both the member and the participating attorney have signed and dated the form.

  8. Failing to Submit Correctly: Not following the submission guidelines can lead to processing delays. Be sure to send your claim via the correct fax number, email, or mailing address.

  9. Not Keeping Copies: Failing to keep copies of the submitted claim and supporting documents can be problematic. Always retain a copy for your records in case you need to reference it later.

Key takeaways

Filling out the Texas Legal Claim form accurately is crucial for ensuring that claims are processed efficiently. Here are some key takeaways to keep in mind:

  • Complete Participant Information: Make sure to fill in all required fields in Part 1, including your name, subscriber ID, and contact details. This information helps identify you and your claim.
  • Provide Client Information: If the client is not the member, include their details in Part 2. This includes the client's name, date of birth, and relationship to the member.
  • Eligibility Verification: Before providing services, contact TLPP to verify eligibility. This step is essential to avoid complications later on.
  • Document Services Performed: In Part 5, list all services rendered, including dates, descriptions, and charges. Accurate documentation is vital for reimbursement.
  • Understand Court Related Information: Fill out Part 6 carefully with court details. This includes the court name, charge date, and docket number, which are necessary for processing your claim.
  • Submit Claims Properly: Follow the instructions in Part 8 for submitting your claim. You can fax, email, or mail your claim to TLPP, ensuring that you choose the method that works best for you.
  • Authorization Signatures: Both the member and attorney must sign in Part 7. Their signatures affirm that the information provided is accurate and that services were rendered.
  • Finalization of Legal Matters: By submitting the claim, you confirm that the legal matter has been finalized. TLPP does not make interim payments, so this is a critical point.
  • Keep Copies: Always retain copies of the submitted claim and any supporting documents. This can be useful for future reference or if any issues arise during processing.

By following these guidelines, you can navigate the Texas Legal Claim form process more smoothly and enhance the likelihood of timely payment for legal services rendered.

⇓ Texas Legal Claim PDF

Steps to Using Texas Legal Claim

Filling out the Texas Legal Claim form is a straightforward process, but it requires attention to detail. Each section of the form must be completed accurately to ensure that your claim is processed smoothly. Follow these steps carefully to provide the necessary information.

  1. PART 1: PARTICIPANT INFORMATION - Fill in your name, Subscriber ID, Group ID, mailing address, city, state, zip code, email address, and phone numbers (home/cell and office).
  2. PART 2: CLIENT INFORMATION - If the client is not you, provide the client's name, date of birth, relationship to you, and contact phone number. Check the box to certify that the client was under 25 at the time of the legal matter if applicable.
  3. PART 3: COVERAGE VERIFICATION - Contact TLPP to verify eligibility before providing services. Record the date and authorization number. Note that obtaining verification does not guarantee payment.
  4. PART 4: ATTORNEY INFORMATION - Enter your name, TLPP ID, billing address, city, state, zip code, email address, telephone number, and fax number. Ensure your contact information is updated.
  5. PART 5: SERVICES PERFORMED - List the first date of service, final date of service, service code, description, quantity/hours, and charge. Calculate and enter the total amount.
  6. PART 6: COURT RELATED INFORMATION - Fill in the court/administrative charge date, first filing date, court/agency name, and cause/docket number.
  7. PART 7: AUTHORIZING SIGNATURES - Sign and date the form as the member or authorized person, authorizing the release of information necessary to process the claim. The attorney must also sign and date, certifying the services provided were necessary and accurate.
  8. PART 8: CLAIM SUBMISSION - Submit the claim via fax, email, or mail to the provided addresses. Ensure you understand that submitting the claim affirms the legal matter is finalized.

After completing the form, double-check all entries for accuracy before submission. This attention to detail can help avoid delays in processing your claim.