Humana Claim Form - Rogers Benefit Group
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1For use with the Humana Family
Health Benefits Claim Form
of Health Insurance and
Health Plan Companies
To Be Completed By Member
1. Complete ALL information requested below.
INSTRUCTIONS
2. Use separate form for each family member and for each accident or illness.
3. Enclose ORIGINAL itemized bills. Please keep a copy for your records. Cancelled checks ARE NOT acceptable.
4. ASSIGNMENT: If you wish benefits to be paid directly to the physician or provider of service, sign the Direct Payment block
below. NOTE: Benefits for hospital confinement will be paid directly to the hospital.
5. Mail completed form to the address on the back of your insurance card.
1. Employee/Member Name (Last)
(First)
(M.I.)
2. Member ID (11 characters):
3. Group Number
5. Group Name
4. Employee/Member Home Address
6. Employee/Member Birth Date:
7. Patient Birth Date:
8. Patient's Name (Last)
(First)
(M.I.)
9. Patient's Relationship to Employee:
10. Service Dates
Place of
Diagnosis
Days or
Unit
From
To
Service*
CPT Code/Service Description
Code
Units
Charges
Total Charges
*Place of Service Codes
11.
Physician, Supplier and/or Group Name
11 - Doctor's Office
Address, Zip Code, Telephone No. and Tax ID No.
12 - Patient's Home
20 - Urgent Care
21 - Inpatient Hospital
22 - Outpatient Hospital
23 - Emergency Room
24 - Ambulatory Surgical Center
31 - Skilled Nursing Facility
32 - Nursing Home
41/42- Ambulance Land/Air
52 - Psychiatric Facility Inpatient
55 - Residential Substance Abuse Treatment Facility
72 - Rural Health Clinic
81 - Independent Laboratory
99 - Other Locations
RELEASE OF INFORMATION
If Payment Is To Be Sent Directly To Provider
I authorize the release of any medical information
necessary to process this claim. I understand
that, as permitted by law, to the extent of benefits
I hereby authorize payment directly to the provider of services and I understand that I am
paid under this claim, the Plan acquires all rights
financially responsible for the hospital, medical, or physician charges not covered by this
of recovery I may have against other parties
authorization.
considered responsible for these expenses.
12. Patient or Authorized Person's Signature
Date
13. Employee's Signature
Date
Any person who knowingly and with intent to defraud any insurance company and files a
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.
GNA02NHHH
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