Nippon Life Insurance Company of America, Attn: Claim Center, P.O. Box 4387, Clinton, IA 52733
Ningen Dock (Executive Physical) Claim Form
Use this form for Ningen Dock enhanced physical exams only. (DX Z00.00: General Adult Examination)
Part A: Patient Information
Patient Name (Last Name, First Name)
Member Name IF NOT THE PATIENT (Last Name, First Name)
Group Name Group Number
In order to process payment of professional services, I authorize any physician, hospital, or other medical provider to release to Nippon Life Benefits, or their representatives, any information regarding my or a family member’s medical history, examination results, or diagnosis. A photocopy of this authorization shall be considered as effective and valid as the original.
Patient Signature: _________________________________________________________________________________ Dare: ________________________
Part B. Provider Information
Name (Last Name, First Name)
Clinic Name (If applicable)
Street Address
Was the patient referred to another provider for other Ningen Dock-covered services? Yes No
If yes, please list provider(s): ____________________________________________________________________________________________
Part C. Ningen Dock Exam Information
Submit exam information as an attachment or on this form.
Option 1: Attach the exam package, including date of service(s) and charges.
Option 2: Attach the list of services including CPT(s) &/or CPT description(s) with charges
Option 3. Complete the table below.
Notice: Any person who knowingly and with intent to defraud any insurance company or other person submits a statement of claim or any application form containing any materially false information or who conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent act which is a crime. Such actions may be considered felonies and subject to criminal and civil penalties, including imprisonment and fines.
Provider Signature: Date: _______________________
Billing Instructions
• Send the completed claim form along with any attachments to Nippon Life Benefits either by email or mail.
• Email: JCS@nipponlifebenefits.com
• Mail: Nippon Life Benefits, Attn: Ningen Dock Claims, 1051 Perimeter Drive, Suite 425, Schaumburg, IL 60173
• Providers typically submit claims on behalf of their patients
• If you are a patient requesting reimbursement, please include the paid receipt with your submission.
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