Bcbs Coordination Of Benefits Questionnaire
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2Coordination of Benefits Questionnaire
BCBS P
N
: ___________________________
OLICYHOLDER
AME
BCBS G
#: ___________________________
ROUP
BCBS M
ID #: _________ __________________
EMBER
Your Blue Cross Blue Shield contract contains a Coordination of Benefits (COB) provision. This form is
required by Blue Cross Blue Shield in order for us to process your claims accurately. If you have any
additional questions regarding this questionnaire or if the information below changes, please call the number
found on the back of the identification card. We appreciate your prompt reply.
O
I
:
THER
NSURANCE
Are you or any other member of this Blue Cross Blue Shield policy covered by another medical or dental
insurance policy or any other Blue Cross Blue Shield policy?
No If No, please complete Section D, print, sign, date and return this questionnaire to Blue Cross and Blue
Shield of Texas, P.O. Box 660044, Dallas, TX 75266-0044, indicating "No other insurance."
Yes If Yes, please complete all the fields below that pertain to the member(s) that has the other
Coverage, print and return to:
Blue Cross and Blue Shield of Texas, P.O. Box 660044, Dallas, TX 75266-0044,
Section A
If this does not apply, skip to Section B.
Check those that apply:
Other Health Insurance
Other Dental Insurance
What type of policy is this?
Group
Individual Policy
Student Policy
Medicare Supplemental
Other Insurance Carrier’s Name: ________________________________________
Address: ______________________________________________
City, State, Zip: _________________________________________
Phone Number: _______________________________
Dependent(s) listed on the other insurance:
Effective or Cancel Date, if different from policyholder:
___________________________________________
____/____/_____
___________________________________________
____/____/_____
___________________________________________
____/____/_____
Other Insurance Policyholder’s Name: _____________________________________
Policyholder’s Date of Birth: ____/____/______
ID # _____________
Effective Date of Other Insurance: ____/____/_____
If Cancelled, Cancellation Date: ____/____/_____
Is the policyholder:
Actively working for the group
Inactive
Retired, retirement date: ____/____/______
On COBRA, which began: ____/____/______
Policyholder’s Employer: _____________________________________
Employer’s Address: ________________________________________
City, State, & Zip: ___________________________________________
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