State University Of New York Medical Reimbursement Form - Claims Incurred Inside The United States
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1
2State University of New York
Medical Reimbursement Form –
Claims incurred inside the United States
Please use a separate claim form for each patient. Your cooperation in completing all items on the claim form, signing the back of the
form and attaching all required documentation will help us to process your claim quickly and accurately.
PLEASE TYPE OR PRINT • USE A SEPARATE FORM FOR EACH PATIENT
MEDICAL INFORMATION
PATIENT INFORMATION
PRIMARY POLICY HOLDER INFORMATION (on ID Card)
NAME
Last
First
Middle
CERTIFICATE NUMBER
GROUP NAME
COLLEGE/ UNIVERSITY NAME
SUNY
BIRTH DATE
SEX
RELATION TO SUBSCRIBER
NAME
Last
First
Middle
M
F
Self
Spouse
Son
Daughter
DOES THE PATIENT HAVE OTHER HEALTH INSURANCE COVERAGE?
ADDRESS
YES
NO
NAME OF OTHER HEALTH INSURANCE COMPANY
CITY
STATE
ZIP CODE
POLICY NUMBER of PRIMARY POLICY HOLDER
HOME PHONE NO.
COLLEGE ID NUMBER
(
)
area code
INJURY QUESTIONNAIRE
If the condition related to this referral is a result of an accident/injury, please complete the following section
Date of accident or beginning of condition:
Month
Day
Year
Describe exactly how the accident took place:
Please indicate if the injury was related to any of the following:
School related Injury
Sports related injury
Work related accident or illness
Automobile/Motorcycle accident
intercollegiate sport
intramural sport
If the condition is a work related accident or a auto/motorcycle accident, please provide the following information:
Name of Employer:
(For work related accident)
Name of Insurance Carrier:
Policy #:
(For auto/motorcycle accident)
Address:
Phone Number:
Contact:
MEDICAL INFORMATION
Use this section to report any COVERED health service which has not already been reported to this HTH Worldwide Plan. Attach itemized bill or
photocopy. Please be sure that duplicate bills are not submitted. Balance forward bills or canceled checks are not acceptable.
Date of Service
Provider of Service
Service Rendered
Total
Illness or Diagnosis
(Mo/Day/Yr)
(Name of Doctor, Lab, Ambulance Company, etc.)
(Office Visit, X-ray, Prescription, etc.)
(Please Indicate Currency)
GRAND TOTAL
SUNY Claim Form 0610
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