Notice Of Data Event

Claim Submission Instructions

Part C – Physician

How to file a TDI Claim as a Physician

Thank you for your assistance in providing key information needed to process your patient’s TDI Claim. To ensure timely processing of your patient’s claim submission, please ensure that you complete each step.

1. Download the TDI Claims Form through the button below. *Form will open in a new browser tab.

2. Complete Part C of the Claim Form. *Please note that all sections of Part C must be completed to process your claim.

3. Print and sign the completed form. *We accept actual signatures on the form or certified digital signatures.

4. Scan and save the signed completed form.

5. Use the button below to submit/upload your completed form.

You can upload your completed form, supplemental information, and additional information you feel will help with the processing of your patient’s claim through Pacific Guardian Life’s Encyro secure messaging service. *Encyro will open in a new browser tab.

For information on Claims Administration, click here.

Should you have any questions on completing or submitting the form, please call (808) 942-1282.