Patient Claim Form Page 2

Claim Form

USE SEPARATE FORM FOR EACH PATIENT

E. OTHER INSURANCE INFORMATION





IS PATIENT COVERED BY ANOTHER MEDICAL PLAN?

YES

NO

IF YES, INDICATE MEDICAL PLAN NAME

POLICY NUMBER ______________________________

IDENTIFICATION NUMBER

EFFECTIVE DATE OF COVERAGE ________________

NAME, ADDRESS AND PHONE # OF OTHER CARRIER

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

EMPLOYER’S NAME

Phone

EMPLOYEE BIRTH DATE ____________________

SPOUSE’S BIRTH DATE _____________________

IF YOU ARE ELIGIBLE FOR MEDICARE:



Submit bills for all charges except prescription drugs to Medicare first. Make sure you keep a copy of the itemized bill, since you will also need to submit it to SIHO.



You will receive the Explanation of Benefits Statement from Medicare, indicating payment or denial of your claim submission. Submit the Medicare statement and a copy of itemized bill to SIHO.



Some physicians and other medical providers will file your Medicare claims directly for you. You need to tell them to send you a copy of the itemized bill also, since you need to send it to SIHO

once you receive Medicare’s Explanation of

Benefits.

F. PATIENT AUTHORIZATION

To all physicians and other medical professionals, hospitals and other medical care institutions, and to insurers, medical or hospital service

and prepaid health plans, employers and group policyholders, contract holders or benefit administrators:

You are authorized to provide any benefit plan administrators, consumer reporting agencies, attorneys and independent claim administrators



acting on SIHO’s behalf, with information regarding the Patient. This information will be used for the purpose of evaluating and administering

claims for benefits.

I hereby authorize SIHO to provide the information relating to medical services and treatment rendered to me and/or my dependents.



I understand that the duration of the authorization is for the term of coverage of the policy or contract under which a claim for health benefits



has been submitted. I understand that I have a right to receive a copy of this authorization upon request. I agree that a photographic copy

of this authorization is as valid as the original.

I have furnished the information on this form so that SIHO may consider this claim. By signing below, I certify the information is correct and



the expenses were incurred by the patient named above.

Should there be an overpayment in excess of the amount payable under the Medical Plan, I agree to reimburse SIHO to the extent of the



overpayment.

PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE

RELATIONSHIP OF AUTHORIZED PERSON

DATE

G. PAYMENT AUTHORIZATION

PAY TO ME

PAY TO PROVIDER





I authorize benefits to be paid to me. I understand it is my responsibil-

I authorize benefits to be paid directly to the physician or other provider of service.

ity to pay the physician, hospital, or other provider of service.

EMPLOYEE / RETIREE / SURVIVOR SIGNATURE

DATE

EMPLOYEE / RETIREE / SURVIVOR SIGNATURE

DATE

Before you submit your claim…..

SUBMIT TO

P.O. Box 1787, Columbus, IN 47202-1787

1. Be sure that all fields are completed.

Call Local: (812) 378-7070 or

2. Make photocopies of all receipts and completed forms. Receipts will not be returned.

Toll Free in Indiana 1-800-443-2980

3. Write your SIHO Member ID number on all paperwork you submit.

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