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Guardian GG-016453: Group Cancer Claim Form

Employees with Guardian group cancer insurance file GG-016453 to claim benefits after a cancer diagnosis or treatment. The treating physician's statement answers whether the tumor is malignant or in situ, the TNM classification, biopsy and prior invasive cancer, then itemizes hospitalization, surgery, chemotherapy and radiation with ICD, CPT and HCPCS codes, dates and charges, so Guardian can match services to the policy's benefits.

Who completes it

The employee or member completes page 1 and signs the authorization on page 2. The treating physician completes the Physician's Statement, Sections 1 to 5, and signs the attestation.

Submitting and payment

How to submit it
The claim goes to Guardian by fax, email or mail, or electronically through Guardian's forms and claims page using the Send a document link.
Who pays
The form sets no fee for the physician's statement; Section 3 notes the patient is responsible for the cost of the medical records.

Good to know

  • A pathology report must accompany the first claim for a cancer diagnosis; if the diagnosis was made clinically, the clinical evidence that established it is sent instead.
  • Internal cancer, as Guardian defines it here, excludes skin cancer except melanomas with specific classifications, so the employee answers internal and skin cancer questions separately.
  • Section 4 asks for the place of surgery (office, surgical center, outpatient or inpatient hospital) and an itemized bill when there are more service dates than lines.
  • Section 3 asks for progress notes, test results, discharge summaries, operative and consultation reports to speed processing and reduce follow-up requests. Edition 12/17.

Get the official form

Download the current version from the source each time; forms change without notice.

Group Cancer Claim Form

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

What does the physician answer on Guardian's cancer claim form?

Section 1 asks for the condition treated, symptom onset, first consultation, prior similar conditions, whether a biopsy was done, whether the tumor shows uncontrolled growth, invades normal tissue or is carcinoma in situ, the TNM classification, any history of another invasive cancer, and whether this is a recurrence or spread.

Which codes does GG-016453 require?

Section 4 uses the admitting diagnosis and ICD code for hospital stays, diagnosis ICD and surgery CPT codes for procedures, HCPCS or CPT codes with drug name and administration method for chemotherapy, and CPT codes for radiation therapy, each with dates and charges.