Form 63046-0314 - Other Insurance Company Information - Florida Blue
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2Other Insurance Company Information
Member Name: _____________________________________________________
Member ID Number: ________________________________________________
Please fill in the squares that apply to you.
If you have more than one insurance policy with other coverage,
please complete a separate copy of this form.
Florida’s Blue Cross and Blue Shield Plan
SECTION A
Do you and/or a member of your family have other health or pharmacy insurance in addition to Florida Blue?
£ Yes, please complete sections B, C and E
£ No, please complete section E
Do you and/or a member of your family have Medicare?
£ Yes, please complete sections D and E
£ No, please complete section E
SECTION B: OTHER HEALTH OR PHARMACY INSURANCE INFORMATION
Name of Other Health or Pharmacy Insurance Company:
Other Insurance Street Address
City
State
Zip Code
Type of Insurance: Employer Coverage: £ Health £ Pharmacy £ Both
Individual Coverage: £ Health £ Pharmacy £ Both £ Medicare Supplement
£ Medicare Advantage £ Other__________________________________________________________
RxBIN*:
PCN*:
*for Pharmacy coverage only
*for Pharmacy coverage only
Type of Coverage: £ Single £ Family £ Employee and Child Only
£ Employee & Spouse Only £ Children Only £ Spouse Only
Name of Policyholder
Date of Birth
Policyholder’s Sex
Employment Status
|
|
£ Female £ Male
£ Active £ Retired £ Cobra
Other Insurance Policy No.
Group #
Policyholder’s Employer
Policy Effective Date
Other Policy Phone #
|
|
If Employer coverage, how many employees? £ Less than 20 £ 20-99 £ 100 or more £ Unknown £ Not Applicable
Person Covered by Other Policy
Date of Birth
Relationship
1. _________________________________________________ ____/____/____
__________________________________
2. _________________________________________________ ____/____/____
__________________________________
3. _________________________________________________ ____/____/____
__________________________________
4. _________________________________________________ ____/____/____
__________________________________
SECTION C: Complete this section if you have dependent children affected by a divorce, legal separation, court-decreed
custody/guardianship or child support order.
Does a court-decree state who has financial responsibility for providing health coverage for any dependent also
covered by Florida Blue?
£ No £ Yes, the court-decree specifies that ____________________________________________ has responsibility.
Name(s)/Relationship(s)
Child’s Name
Custodial Parent Name
Non-Custodial Parent
Joint Custody
Person with whom child lives
and Date of Birth
Name and Date of Birth
Yes
No
£
£
£
£
£
£
Please provide a copy of the insurance card or insurance information for each policy that covers the dependents
listed above, if not already provided in Section B.
Please complete and sign the other side >
63046-0314
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Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc., an Independent Licensee of the Blue Cross and Blue Shield Association.
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Parent category: Business