Form 63046-0314 - Other Insurance Company Information - Florida Blue Page 2
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2SECTION D: Medicare Coverage
Sex
Part A: Effective Date
/ /
Term Date / /
Subscriber’s Name
Medicare HIC No.
£ Female
Part B: Effective Date
/ /
Term Date / /
£ Male
Part D: Effective Date
/ /
Term Date / /
RxBIN*:
PCN*:
*for Medicare Part D only
*for Medicare Part D only
Reason(s) for Medicare £ Age £ Disability
Date of First Dialysis Treatment
Location Treatment
£ End Stage Renal Disease
/
/
£ In Home £ Dialysis Facility
Spouse or Dependent Name
Sex
Medicare HIC No.
Part A: Effective Date
/ /
Term Date / /
£ Female
Part B: Effective Date
/ /
Term Date / /
£ Male
Part D: Effective Date
/ /
Term Date / /
RxBIN*:
PCN*:
*for Medicare Part D only
*for Medicare Part D only
Reason(s) for Medicare £ Age £ Disability
Date of First Dialysis Treatment
Location Treatment
£ End Stage Renal Disease
/
/
£ In Home £ Dialysis Facility
SECTION E: This section must be completed and signed by the subscriber.
Date of Birth
Spouse’s Social Security No.
Spouse’s Name (If Applicable)
/
/
–
–
Is your spouse employed and eligible for coverage through his/her employer? £ Yes £ No
If yes, did your spouse elect not to have coverage through his/her employer’s group insurance? £ Yes £ No
To the best of my knowledge the information provided is true, accurate and complete. Unanswered questions indicate
they do not apply. My signature authorizes any Medicare carrier, intermediary, insurance carrier or plan to make available
to Florida Blue all information concerning claims filed by me or on behalf of myself or my covered dependents.
_________________________________________ ___/____/____ (_____) __________ ( ____) _________ ___/___/____
Subscriber’s Signature
Date of Birth
Work Phone No.
Home Phone No. Today’s Date
Thank you for completing this form.
You can send us your form by mail:
Florida Blue
OPL Dept.
PO Box 45287
Jacksonville, FL 32232-9805
Or fax to: 1-904-997-5224
FOR OFFICE USE ONLY:
Member ID Number:
Department:
Group Number:
Tracking Number:
Market Segment:
63046-0314
2
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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