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new.html
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---
title: File a Claim
---
{% include head.html %}
<link href="{{site.baseurl}}/stylesheets/form.css" type="text/css" rel="stylesheet" />
<body class="no-js layout-claims layout-claims-new">
<a class="a-skip-to-main" href="#main">Skip to main content</a>
{% include site-header.html %}
<main role="main" id="main">
<div class="wrapper">
<h1>File a claim</h1>
<form id="claim" action="{{site.baseurl}}/claims/step-2/"></form>
<div id="form-errors"></div>
<aside>
<h1>How it works</h1>
<ol class="steps">
<li>Fill out and submit this form.</li>
<li>We’ll send you a code, which you’ll give to your healthcare provider. Using this code, your provider will share information relevant to your claim.</li>
<li>We’ll process your application. The average claims-processing time is currently <span class="average-claim-time">18 days</span>.</li>
<li>You’ll receive your benefits.</li>
</ol>
<p>More detailed information is available <a href="{{site.baseurl}}/claims/how-it-works/">here</a>. If you have any questions, don’t hesistate to <a href="{{site.baseurl}}/contact-us/">contact us</a>. You can also <a href="{{site.baseurl}}/eligibility/">read eligibility information</a>, <a href="{{site.baseurl}}/estimator/">estimate your benefits</a>, or <a href="{{site.baseurl}}/forms-and-publications/">request a paper form</a>.</p>
</aside>
</div>
</main>
{% include site-footer.html %}
</body>
<script type="text/javascript" src="{{site.baseurl}}/javascripts/lib/underscore.js"></script>
<script type="text/javascript" src="{{site.baseurl}}/javascripts/lib/jsonform.js"></script>
<script>
$( document ).ready(function() {
// Get the JSON Schema and form definitions
var json_form = $.get("{{site.baseurl}}/javascripts/form.json");
var json_schema = $.get("{{site.baseurl}}/javascripts/schema.json");
// When the schema and form are available, render the form
$.when(json_schema, json_form).done(function() {
JSONForm.fieldTypes['title'] = {
template: '<h2><%=node.value %></h2>'
};
JSONForm.fieldTypes['section-title'] = {
template: '<h3><%=node.value %></h3>'
};
JSONForm.fieldTypes['instructions'] = {
template: '<p class="instructions"><%=node.value%></p>'
};
$('#claim').jsonForm({
"schema": json_schema.responseJSON,
"form": json_form.responseJSON,
onSubmit: function (errors, values) {
if (errors) {
$('.form-errors').html('<p>Please fix the below errors.</p>');
}
else {
// Set this to a valid endpoint to receive the JSON form contents.
$.post('{{site.baseurl}}/claims/step-2/', values);
window.location('{{site.baseurl}}/claims/step-2/');
}
}
});
$('.layout-claims-new form')
.on("change", 'select[name="information.reason"]', function(){
if ($(this).val() == "Manage a recently diagnosed medical condition.") {
$('.dependent').hide();
$($('h2')[3]).hide();
$($('h3')[3]).hide();
} else {
$('.dependent').show();
$($('h2')[3]).show();
$($('h3')[3]).show();
}
})
.on("change", 'input[name="payment.method"]', function(){
var val = $('input[name="payment.method"]:checked').val();
if (val == "direct deposit") {
$('.direct_deposit').show();
} else {
$('.direct_deposit').hide();
}
})
.on("change", 'input[name="claimant.address.street"], input[name="claimant.address.city"], input[name="claimant.address.state"], input[name="claimant.address.zip"]', function(){
dependent_address_street = $('input[name="dependent.address.street"').val();
dependent_address_city = $('input[name="dependent.address.city"').val();
dependent_address_state = $('input[name="dependent.address.state"').val();
dependent_address_zip = $('input[name="dependent.address.zip"').val();
dependent_address = dependent_address_street && dependent_address_city && dependent_address_state && dependent_address_zip;
if (dependent_address == "") {
claimant_address_street = $('input[name="claimant.address.street"').val();
claimant_address_city = $('input[name="claimant.address.city"').val();
claimant_address_state = $('input[name="claimant.address.state"').val();
claimant_address_zip = $('input[name="claimant.address.zip"').val();
$('input[name="dependent.address.street"').val(claimant_address_street);
$('input[name="dependent.address.city"').val(claimant_address_city);
$('input[name="dependent.address.state"').val(claimant_address_state);
$('input[name="dependent.address.zip"').val(claimant_address_zip);
}
});
$('.layout-claims-new form input[value="prepaid debit card"]').click()
}).fail(function() {
console.log('JSON schema and form could not be retrieved');
});
});
</script>