LTC Claims Forms

Do you currently have an active Long Term Care claim and are in need of a form?

Browse Genworth’s collection of long term care insurance claims forms below. If you have not already done so, please download Adobe Reader to view the forms. Once you locate the appropriate long term care insurance claims form, download and complete it in full. Print the form, sign it and return it to Genworth. The forms can be returned via email, fax or the address on the form. If you have registered your account online, you may also upload your completed form to the web.

These long term care claims forms will assist you in conducting authorizations, changing addresses and conducting other updates to your policy/certificate. Please be sure to include your policy number and claim number on the completed forms.

If you do not have an active claim, but are looking for long term care insurance forms, please visit our LTC Forms and Documents page.

Claimant Forms

Electronic Funds Transfer Claims authorization
Request benefit payments be directly deposited into your bank account.

Address Change
Use when updating the mailing address for the insured, attorney-in-fact, guardian/conservator or other.

Assignment of Long Term Care Insurance Benefits
Use when assigning benefit payments directly to a long term care facility or home care agency.

Use when authorizing a third party to receive financial and/or health information relevant to the claim.

Payment Withhold Authorization Form
In order to expedite the overpayment resolution process, we encourage you to sign and return this form for our records. If any overpayment is ever identified, we will notify you in writing as to the nature and amount of the overpayment, prior to any withholding.

Provider Forms

Invoice for Independent Care Providers
In the event that an independent care provider is being utilized, he/she will utilize this form as an invoice to submit charges for care provided.

Completed by a representative at the long term care facility where the claimant resides, to verify ongoing confinement.

Community Care Information Form
In the event that an Adult Day Care and/or Home Health Care Agency review is requested, this form will be utilized to adjudicate the provider according to the policy requirements.

206401E1FRM 05/24/23