Forms

For reimbursement, complete items
1-9 of the claim form, attach receipt(s) and submit to:

Tri-County Schools Insurance Group

c/o Delta Health Systems

P. O. Box 80

Stockton, CA 95201-3080

If you need Delta Health Systems to reimburse the provider, then also sign item 10 and following the same procedures listed above.

One claim form per patient.

JPA Delegate Forms

Our Mission is to pool risk and purchasing power of public entities to provide quality programs to our participants in an effective manner while emphasizing customer satisfaction, stability, financial solvency and cost.

866-822-5299
1176 Live Oak Blvd • Suite A

Yuba City, CA 95991

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