These forms apply to any policy:

• Pay Provider Direct
Use this form if you want us to send your benefit check directly to your care provider.


• Stop Pay Provider Direct
Use this form when you want to stop direct payments to your care provider and benefits will be sent to you.


• HIPAA Authorization Designation
Use this form to designate a person or persons who can receive information from us about your policy and claims.


• Health Information Authorization
Use this form to release your protected health information to Equitable Life & Casualty.

These forms apply to EquiCare 2002 and 2020 policies. Before using these forms please contact the Specialty Unit to inquire about eligibility for benefits.

Caregiver Applications:

• Care by Family Member I
Use this application if you want a family member to provide care for you in the near future and you are seeking approval.


• Care by Family Member II
Use this application if a family member is currently providing care and you are seeking approval.


• Private Caregiver I
Use this application if you want a private caregiver to provide care for you in the near future and you are seeking approval.


• Private Caregiver II
Use this application if a private caregiver is currently providing care and you are seeking approval.

Guidlines for using Caregiver Time Record and Notes

Sample Time Record

Caregiver Time Record/Caregiver Note

• Initial Assessment
Use this form for your initial assessment or as a resource for your assessment form to see if you would need to add any additional information to your current form.


• Caregiver Note
Use this form for caregiver documentation or as a resource for the caregiver note your use to see if you would need to add any additional information to your current form.
*Please note how level and frequency of care provided is documented.

If you are unsure of the form number which applies to the policy please call the EquiCenter at 800-352-5170 for assistance.

• Long Term Care Insurance Claim Form 5080000001 (Red - 2 pages)
The following forms require prior approval for benefits. If the elibigility requirements have not been met please contact our Intake Unit at 1-800-352-5150 ext. 3315.


Use this to file a claim for any of the policy form #'s listed below:


Long Term Care Policy form #640, 750, 790, 8000
Nursing Facility Care Policy form #680
EquiCare Policy form #2002, 2020

• Long Term Care Insurance Claim Form 5380000001 (Green - 3 pages)
Use this to file a claim for any of the policy form #'s listed below:


Recovery Plan Policy form #435
Extended Care Facility Policy form #464, 474
Long Term Care Policy form #650
Convalescent Care Policy form #660
Nursing Care Recovery Policy form #690