The Texas Legal Claim form is a document designed to facilitate the submission of claims for legal services provided under specific coverage plans. It collects essential information about the member, client, attorney, and the services performed. Understanding this form is crucial for ensuring that claims are processed efficiently and accurately.
The Texas Legal Claim form serves as a crucial document for individuals seeking to navigate the complexities of legal services under the Texas Legal Protection Plan (TLPP). This form is divided into several sections, each designed to gather essential information from participants and their legal representatives. The first part collects participant details, including the member's name, subscriber ID, and contact information. Following this, client information is required if the individual seeking services is not the member themselves. A vital aspect of the form is the coverage verification section, where participants must confirm their eligibility for services by contacting TLPP. Legal representatives must also provide their details, ensuring that all billing and communication channels are clear. The form includes a section for services performed, where attorneys list the dates of service, descriptions, and charges, aligning with the TLPP fee schedule. Additionally, court-related information is captured to ensure all legal matters are properly documented. The submission process is straightforward, with clear instructions on how to send the completed form via fax, email, or traditional mail. Importantly, participants must sign to authorize the release of necessary information and affirm the accuracy of the details provided. This comprehensive approach ensures that all claims are processed efficiently, safeguarding the rights of both members and their legal representatives.
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: ,
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
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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