Coordination Of Benefits Questionnaire - Empire Blue Cross Blue Shield Page 2
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1
2S
ubscriber Name:
Subscriber Identification Number:
Section 4 –
Medicare Enrollee Information
Name of Beneficiary
Coverage Type
Effective Date
Medicare Entitlement Reason
(mmddyyyy)
Kidney Failure
Part A
st
Age
Disability
Date of 1
treatment:
Part B
___/___/____
Part D
Kidney Failure
Part A
st
Age
Disability
Date of 1
treatment:
Part B
Part D
___/___/____
Section 5 – Covered Persons
Complete the following information for all persons covered under the other policy – including the subscriber in
section 3 (attach a separate sheet if additional space is needed)
Relationship to the subscriber in
section 3
Date of Birth
Fill in if covered
Name (first and last name)
(i.e., self, spouse, child, step-child, custodial parent)
(mm/dd/yyyy)
by Medicare
a)
SELF
b)
c)
d)
Section 6 – Dependent Children
(only to be completed if there are dependent children covered under the
other policy and the parents are divorced or legally separated)
If there is a legally binding agreement for health care
Mother
Father
Joint
Legal
expenses, who is responsible? Attach a copy of the
Agreement
Guardian
Court Order
If there is no legally binding agreement, who has primary
Mother
Father
Joint
Legal
custody (custodial parent)?
Custody
Guardian
Which dependent children in section 5 above does this
C
B
D
All
apply to?
Section 7 –
Contract Holder Signature
Insurance Fraud Statement: I understand that any person who knowingly and with intent to defraud any insurance company or other person, files an
application for insurance or statement of claim containing any materially false information, or conceals, for the purpose of misleading, information
concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five
thousand dollars and the stated value of the claim for each such violation.
Signature
Date Signed
-
-
Daytime Telephone Number:
This Coordination of Benefits questionnaire may be completed via:
•
Internet – logon to
•
US Mail – return this form in the enclosed pre-addressed envelope
•
Telephone – contact your Customer Service Center at the toll-free number listed on the back of your identification
card during normal business hours.
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 2
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