Nursing Student Medical Claims

All claims must be submitted by the injured party directly to BMI Benefits/Bob McCloskey Insurance at the contact information below. If you utilize the Franciscan Treatment Center for treatment, please submit the claim form to them, as well.

Please complete this form in its entirety and submit to BMI Benefits/Bob McCloskey Insurance within 90 days from the date of the injury. Claims reported after 1 year of injury will not be considered. Please retain a copy for your records.

Please note that on the claim form, a school official will need to sign, note title, and date the form.

For all questions regarding student injury policy in the School of Nursing and Health Professions please refer to the School of Nursing and Health Professions Injury Policy as listed in your student handbook or contact your respective Program Director or Department Chair(s).

Claim Information

1. To file a claim, please complete this Nursing Medical Claim Form. If seeking treatment at Franciscan Treatment Center, bring claim form to Franciscan Treatment Center (contact information and location below).
2. Submit claim form and expenses/itemized bills which might include medical bills, HCFA 1500 Forms (physician’s office) or UB-04 Forms (hospitals), and/or ADA Dental Claim Forms (dentist) to BMI Benefits/Bob McCloskey Insurance Agency following treatment.  Please do not submit balance due statements. A sample HCFA 1500 Form, UB-04 Form, and ADA Dental Claim Form have been included in the claim form.

Franciscan Treatment Center Information:

1199 Bush Street, Suite 160
San Francisco, CA 94109

Claims Contact: Gayle Chan-Lee, gayle.chan-lee@dignityhealth.org or (415) 353-6305

BMI Benefits LLC - (Bob McCloskey Insurance Agency) Claims Reporting Information:

BMI Benefits, LLC - Bob McCloskey Insurance
P.O. Box 511
76 Main Street, Matawan, NJ 07747

Claims Email Address: vicki@bobmccloskey.com

Nationwide Toll Free Phone Number: 1 (800) 445-3126, x56355

Customer Service Hours: 9 a.m.–5 p.m. (EST)