Return these two forms along with your itemized bills, explanation of benefits (EOB's) from your primary carrier and any cancelled checks for bills you have paid relating to this injury. You should send in the claim form as soon as possible (within 30 days from date of injury). You may send just the claim form and have the Explanation of Benefit's (EOB's) follow at a later date. The important thing is to have the claim on file. You may continue to send any other bills; EOB's, etc. as you receive them, just enclose a note stating that the claim is already on file.

If you do not have primary insurance coverage, please write a letter stating that you did not have any medical insurance at the time of the injury. This letter must be notarized and returned with all itemized bills to the EPYSA office.

There is a $100.00 deductible (this $100.00 is not applied towards your primary deductible, you will have $100.00 deducted from the amount you are requesting for refund).

If you have any questions, please call 215-657-3795 or e-mail (kateobie@epysa.org) Kate.