Form Gf-Frm-0416-001 - Medical Claim Form Page 2
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1
2Member ID (from Health Plan ID card):
Group Number (from Health Plan ID card):
7 8 - 3 6 0 0 0 1
G E H A
Patient Information
Date of birth:
Name (Last, First, MI):
Home address:
Gender:
Relationship to Subscriber /
Policyholder:
M
F
Subscriber/Policyholder
City:
State:
ZIP Code:
Spouse/Partner
New address?
Child
Yes
Other dependent
Phone #:
No
(
)
–
Subscriber/Policyholder Information
(Complete this section only if it is different than the patient information.)
Employee name (Last, First, MI):
Phone #:
(
)
–
Home address:
Date of birth:
State:
ZIP Code:
New Address?
City:
Yes
No
Provider Information
Accident Information
Provider name:
Provider Tax Identification #:
Date of accident:
Provider address:
Type of accident:
Work
Auto
Other
How did the accident happen?
State:
ZIP Code:
City:
Other Insurance
Is the patient covered by another insurance plan?
Yes
No
(
If yes, please complete the following information.)
Name of person carrying other insurance (Last, First, MI):
Date of Birth:
Name of other insurance carrier:
Policy number:
Employer name:
Assignment of Benefits
I agree to assign benefits directly to the provider of services.
Signature:
Date:
GF-FRM-0416-001
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Parent category: Legal