A letter is sent when a vehicle, with a current registration, has "no valid insurance" for 10 or more consecutive days in the Georgia Motor Vehicle database. This form enables us to calculate the correct compensation that may be owed to an injured employee.Insured's ID Number. (Patient's Medicare Health Insurance Claim Number - HICN). How to fill out the Georgia Health Coverage Application and Instructions? Access Letter of Explanation. How do I file a claim? You can download and fill out a form, called the Patient Request for Medical Payment form (CMS-1490S). Find health insurance forms for customers including medical and dental claims forms, authorization forms, appeals, pharmacy forms, and more. When you submit your own claim to Medicare, complete the entire form.