Coordination Of Benefits Questionnaire - Empire Blue Cross Blue Shield

ADVERTISEMENT

Subscriber Name:
Subscriber Identification Number:
COORDINATION OF BENEFITS QUESTIONNAIRE
Instructions: Please fill out all applicable sections completely by filling in the applicable circle(s) within each section and
print clearly in black or blue ink in order for us to quickly and accurately process your request.
Section 1 – Member Insurance Information
Are any family members that are covered under
Yes
Medicare Only
Medicaid
No
the policy above covered under any other group
ESRD
CHAMPUS/
health insurance policy (currently or during the
TRICARE
past 2 years)?
Complete
Complete sections 3 -
Skip to section 7
Skip to section 7
sections 2 – 7
5 and 7
Section 2 – Other Insurance Information
Indicate name of other insurance carrier (fill in only one)
(NOTE: If more than one other coverage, please provide the other carrier information from this section on an additional page.)
Aetna / US Healthcare
Blue Shield of NENY
CDPHP
CIGNA
GHI
HIP
Horizon BC of NJ
MVP
Oxford
United Health Care
Other
(Name of Carrier)
Customer Service Telephone
-
-
Number:
Type of enrollment
Individual
Family
Employee & Spouse
Parent & Child(ren)
(fill in only one):
Type of coverage
Hospital
Medical
Prescription Drug
(fill in all that apply):
Dental
Vision
Mental Health / Substance Abuse
Effective dates of the other
coverage:
Effective Date (mmddyyyy)
Termination Date (mmddyyyy)
(if applicable)
Section 3 –
Primary Contract Holder Information of Other Insurance
Last Name
First Name
Primary Contract Holder on the policy
indicated in section 2:
Identification Number or Medicare ID
number: (Include all letters and prefix)
Group Number:
(If Available)
Relationship of this contract holder to the contract holder listed at the top of this form:
Self
Spouse
Dependent
Ex-Spouse or
Legally Separated
Other
Spouse
If relationship is “SELF” or “SPOUSE”, indicate employment status
Actively working with employer offering other coverage
Not Actively Working/Long Term Disability
If retired, date
Retired from employer providing other
of retirement:
coverage
Continued on next page
Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield
Association, an association of independent Blue Cross and Blue Shield Plans.
Page 1

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 2