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- Long Term Care Claims
- Ltc Claims Forms
Do you currently have an active Long Term Care claim and are in need of a form?
Browse Genworth’s collection of long term care insurance claims forms below. If you have not already done so, please download Adobe Reader to view the forms. Once you locate the appropriate long term care insurance claims form, download and complete it in full. Print the form, sign it and return it to Genworth. The forms can be returned via email, fax or the address on the form. If you have registered your account online, you may also upload your completed form to the web.
These long term care claims forms will assist you in conducting authorizations, changing addresses and conducting other updates to your policy/certificate. Please be sure to include your policy number and claim number on the completed forms.
If you do not have an active claim, but are looking for long term care insurance forms, please visit our LTC Forms and Documents page . Claimant Forms Electronic Funds Transfer Claims authorization Request benefit payments be directly deposited into your bank account.
Address Change Use when updating the mailing address for the insured, attorney-in-fact, guardian/conservator or other.
Assignment of Long Term Care Insurance Benefits Use when assigning benefit payments directly to a long term care facility or home care agency.
HIPAA Use when authorizing a third party to receive financial and/or health information relevant to the claim.
Payment Withhold Authorization Form In order to expedite the overpayment resolution process, we encourage you to sign and return this form for our records. If any overpayment is ever identified, we will notify you in writing as to the nature and amount of the overpayment, prior to any withholding.
To manage your policy/certificate or claim online
Contact LTC Claims: 800.876.4582
Hours Monday – Thursday: 8:30 AM – 6 PM ET, Friday: 9 AM – 6 PM ET Fax Number Fax your documents to 888.557.5526
LTCI Claims Invoice Email [email protected]
LTCI Document Review Email [email protected]
USPS Mailing Address Genworth Financial Long Term Care Claims P.O. Box 40007 Lynchburg, VA 24506
FedEx and UPS Mailing Address Genworth Financial Long Term Care Claims 3100 Albert Lankford Drive Lynchburg, VA 24501
Provider Forms
In the event that an independent care provider is being utilized, he/she will utilize this form as an invoice to submit charges for care provided.
Completed by a representative at the long term care facility where the claimant resides, to verify ongoing confinement.
In the event that an Adult Day Care and/or Home Health Care Agency review is requested, this form will be utilized to adjudicate the provider according to the policy requirements.
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- Hearing Impairments
- Vision Simulation
- Mobility Challenges
- Conversation Starters
- Family Stories
- What is Long Term Care?
- Understanding Medicare & Medicaid
- Cost of Care
- Care Funding
- Care Services
- LTC Insurance Forms
- Life Insurance Forms
- Annuity Insurance Forms
- Index UL Rates
- Prospectuses
- Why Increases are Needed
- Value of Coverage
- Genworth's Promise
- Contacts Login/Register Contact Form
- File a Claim
- The Claims Process
- Change in Care
- Closing a Claim
- Submit a Claim Document
- LTC Claims Forms
- How to Begin A Claim
- Life Insurance Claim Forms & FAQs
- Annuity Claim Forms & FAQs
- Unclaimed Property
- Thought Leadership
- Genworth Newsroom
- Employee Giving
- Genworth Foundation
- Environmental Impact
- Community Investment
- Diversity and Inclusion
- Learning & Development
- Benefits & Well-being
- COVID-19 Preparedness
Long Term Care Insurance Forms
Browse Genworth’s collection of long term care insurance forms below. Once you locate the appropriate long term care insurance form, download and complete in full. Once you’ve printed it out, please sign and return it to the address found directly on your long term care insurance form. If you have not already done so, please download Adobe Reader® download link. Opens in new window to view the forms.
Genworth’s long term care insurance forms will assist you with conducting authorizations, changing your name/address, naming a beneficiary, changing your long term care coverage and conducting other updates to your policy/certificate.
Manage Your Policy/Contract Online
Change your address, billing info, automate payments and more.
California Residents
To view the California Long Term Care Sample Policy, please click the links below, or to request a paper copy, call Customer Service at 888 GENWORTH ( 888.436.9678 ) M-Th 8:30 AM - 6 PM or F 9 AM - 6 PM ET and a sample policy will be mailed to you within 15 calendar days.
California Non-Partnership Sample Policy California Partnership Sample Policy
Navigate Forms
Are you looking for one of these forms?
These are the top three most downloaded long term care insurance forms. We've listed them here for your convenience. If the form you are looking for is not one of these three, all other long term care insurance forms are listed on this page, below.
- Electronic funds transfer (EFT) authorization
- Coverage Change Request Form (all states, excluding MA)
- Authorization to Receive Information
Agent Change Request Use to request a change to the Servicing agent on your policy(ies).
Authorization to Receive Information Use when authorizing a third party to receive information about your policy. The authorized person will be required to provide appropriate security verification for any phone requests for information.
Beneficiary Designation for Long Term Care Insurance Use this form to change the beneficiary on an existing Long Term Care Insurance policy, that has a Return of Premium Rider.
Coverage Change Request Form (all states, excluding CA and MA) This form is used to request benefit changes, and/or update/change address and/or change the payment frequency on a current long term care insurance (LTCI) policy.
Coverage Change Request Form - California Only This form is used to request benefit changes, and/or update/change address and/or change the payment frequency on a current long term care insurance (LTCI) policy for residents of California and for policies that were issued in California.
Coverage Change Request Form - Massachusetts Only This form is used to request benefit changes, and/or update/change address and/or change the payment frequency on a current long term care insurance (LTCI) policy that was issued in Massachusetts.
Deferred Annuity to LTCI 1035 Transfer Authorization Use this form to authorize an exchange from a non-qualified deferred annuity contract to a Long Term Care Insurance policy.
Electronic Funds Transfer (EFT) Authorization Request automatic withdrawals from your bank account to pay premiums on long term care insurance policies, or to update bank account information for policies already drafting premiums.
Immediate Annuity to Long Term Care Insurance Funding Request for Existing Immediate Annuity Contracts With Irrevocable Assignment Use this form to certify that all or the specified portion of your non-qualified immediate annuity payment will directly fund your LTCI policy.
Life Insurance to LTCI 1035 Transfer Authorization Use this form to authorize an exchange from a non-qualified life insurance policy to a long term care insurance policy.
Third Party Changes Add, change or delete a third party listed on your policy.