Coordination Of Benefits Form - Qualcare printable pdf download

QUALCARE COORDINATION OF BENEFITS FORM

If you, your spouse, or dependent(s) have other coverage, please fill out the necessary information. If there is no

other coverage, please complete Section I, IV, and VI. Accurate information is needed so that claims processing

for your family will not be delayed.

Section I – Subscriber Information

Subscriber Name ______________________________________ ID#: __________________________

Section II - Spouse Information

Spouse’s Name ______________________________ Spouse’s Date of Birth _________________________

Spouse’s Social Security Number ____________________________________________________________

Spouse’s Current Employer/Company Name ___________________________________________________

Section III - Please complete the next section if you are divorced or legally separated, and you have covered

dependents under this health plan. Otherwise, continue to Section IV.

Date of Divorce/Separation _________________________________________________________________

Name of Other Biological Parent ______________________________ Date of Birth ___________________

If divorced or legally separated:

Divorce decree states other parent, ________________________________, must provide health benefits.



Divorce decree states joint custody with shared responsibility for medical expenses.



Divorce decree does not state any special provisions.



Other, please explain ___________________________________________________________________



With what parent does the child(ren) reside? ________________________________________________

**A copy of the section of the court decree pertaining to health coverage would be helpful to support your

response.

**You must complete Section IV with insurance information of the other parent.

Section IV - Other Coverage Information

□ No Other Coverage (If you had other coverage while also enrolled under your health plan administered by

QualCare but that coverage ended, please enclose documentation from the former carrier stating your policy

had been terminated.)

Other Insurance Name ________________________________ Other Coverage ID# ___________________

Other Insurance Address/Phone Number ______________________________________________________

_______________________________________________________________________________________

Policy Effective Date ____________________________ Policy End Date ___________________________

Covered Members (please provide the names):

□ Subscriber __________ □ Spouse ___________ □ Children _____________________________________

Is the subscriber: □ Full Time Employee □ Self-employed □ Retired, Date of Retirement: ______________

Type of Coverage:

□ Hospital □ Major Medical □ Prescription □ Dental □ Vision

Section V - Medicare Coverage

Member eligible for Medicare _______________________________________________________________

Effective Date of Part A: _____________________ Effective Date of Part B: _________________________

Reason for Medicare Coverage:

□ Age 65 or older □ Disability □ ESRD, Date Dialysis Treatment Began: ___________________________

Section VI - Subscriber Signature

I certify that the above information is correct and complete to the best of my knowledge. I understand that I am

obligated to provide this information in accordance with my plan. Failure to provide complete and accurate

information may result in the delay or denial of claim payments.

Signature ________________________________________ Date __________________________

Please mail form to: QualCare-Cost Containment Department, 30 Knightsbridge Road, Piscataway, NJ 08854

Coordination Of Benefits Form - Qualcare

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